Clinical nursing handovers for continuity of safe patient care in adult surgical wards: a best practice implementation project

Clinical nursing handovers for continuity of safe patient care in adult surgical wards: a best practice implementation project

Xiaoling Wong¹ Yi Jung Tung¹ Sin Yee Peck² Mien Li Goh^3,4

¹University of Surgical Cluster, National University Hospital, Singapore, ²Alexandra Hospital, Singapore, ³Evidence Based Nursing Unit, National University Hospital, Singapore, and ⁴Singapore National University Hospital (NUH) Centre for Evidence-Based Nursing: a Joanna Briggs Institute Centre of Excellence

The objective of this evidence-based quality improvement project was to improve clinical nursing handovers between registered nurses.

Introduction: Clinical nursing handovers transfer critical information about the patient’s care to oncoming shift nurses. Nurses use structured handover tools to handover patient information. In three adult surgical wards of a Singapore tertiary hospital, a lack of consistency was found in the local handover process when shifts changed. These resulted in ineffective handovers and compromised the patient’s safety. Thus, evidence-based interventions were needed so that patient handovers and continuity in safe patient care could improve.

Methods: This project was implemented in three phases from January 2017 to November 2017 at three adult surgical wards of a tertiary hospital, utilizing the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI PACES) and Getting Research into Practice (GRiP) module. The pre- and post-implementation audits were conducted using JBI PACES audit criteria. An evidence-based four-pronged approach was employed, including adequate human resource coverage during handovers, a structured and standardized handover, visual cues and a teaching video.

Results: The results of the post-implementation audit of nurses performing handovers (n ¼ 33) showed that handovers using standardized documentation improved from 0% to 21.0% ( p ¼ 0.005), which was statistically significant. However, handovers of detailed observations of patients improved from 72.7% to 87.9% ( p ¼ 0.215) and handovers of relevant history of patients improved slightly from 93.9% to 97.0% ( p ¼ 1.000) but was not statistically significant. Medication error incidents related to handovers was reduced by 72% over a six-month period.

Conclusion: The multi-modal approach improved the comprehensiveness and completeness of clinical nursing handovers. These strategies had a significant effect on reducing medication errors related to handovers.

Keywords Clinical nursing handover; evidence-based; patient safety; quality improvement; registered nurses

JBI Database System Rev Implement Rep 2019; 17(5):1003– 1015.

Introduction

_A nursing clinical handover is defined as the transfer of a patient’s data to the next shift, so that the responsibility of care changes from the

preceding nurse to the oncoming nurse.¹ Nursing verbal handovers may happen at the patient’s bed-side or at the nurse’s station, within a cubicle with numerous patient beds, while non-verbal handovers

Correspondence: Mien Li Goh, mien_li_goh@nuhs.edu.sg

There is no conflict of interest in this project.

DOI: 10.11124/JBISRIR-2017-004024

involve oncoming nurses reading and checking the patient’s updated electronic information on their own.^2,3 During clinical handovers, nurses use struc-tured and standardized handover tools to transfer critical patient information to the oncoming shift nurses.^2,3 Nursing handovers occur during the over-lapping time between shifts and generally take place three times a day. During handovers, registered nurses (RNs) of the preceding shift share and discuss patients’ information with the oncoming shift’s RNs, and issues pertaining to the patients’ care will be highlighted and clarified.⁴ This process will guide RNs in planning the patients’ routines and prioritizing

JBI Database of Systematic Reviews and Implementation Reports                 2019 THE JOANNA BRIGGS INSTITUTE             1003

©2019 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT

care needs within the designated shift hours to ensure continuity of care.^4,5 In this way, nurses play a signif-icant role in the transferring of patient information between shifts, since accurate clinical information will ensure the provision of quality and safe nursing care and prevent errors or omissions of care from occurring.³

There are various structures to guide nurses’ clin-ical handovers. These include Identify, Situation, Background, Assessment and Recommendations (ISBAR)⁶ and Situation, Background, Assessment and Recommendation (SBAR)⁷ which is the most frequently used mnemonic in patient handovers. The ISBAR and SBAR are known to be reliable, safe and a standard guide for healthcare professionals to handover critical patient information.^6,7 They are effective communication tools and recommended for use in acute care settings.^6,7 Furthermore, there is an integrated nursing handover system consisting of a structured framework and an electronic tool.⁸ In healthcare service delivery, patient safety concerns and point of care issues have been reported due to poor clinical handovers, such as inadequate or incomplete patient information being handed over. The quality of content plays a significant role when information is transferred between different teams of nurses.^6,8 A lack of a structured guide, breakdown in communication, disorganized information, and/or a loss of critical information during handovers can compromise patients’ safety, causing possible treat-

ment errors, medication errors, delays in treatment as well as patient dissatisfaction.^6,9,10 These events

are preventable as long as appropriate interventions are implemented, such as optimizing handover prac-

tice, which is a major priority when it comes to providing quality of care.^6,7,9,10

A study has suggested that nurses performing clinical handovers using a structured framework and electronic data systems may improve the quality of information handover to oncoming shift nurses.⁸ The structured framework of a handover is mostly guided by electronic documentation, which con-tains critical patient information intended to enhance the clinical handover quality.⁸ Despite the support of electronic documentation and a struc-tured handover process and content, information handed over still lacks consistency and/or accuracy. It is observed that when information relevant to patient care is left out during a handover, it leads to additional work to recover information after the

1. Wong et al.

handover and, in worse scenarios, compromises the patient’s safety.^6,11 Common barriers to effective handovers include, but are not limited to, environ-mental issues such as complex, chaotic and noisy surroundings, nurses multi-tasking during the hand-overs, communication barriers, lack of training, problems associated with standardization, and time constraints.¹²

In the current hospital, during a handover, nurses use a handover recipe card to communicate essential information, which normally consists of a patient’s medical history, his or her current diagnosis, chief complaints, referrals, allied health notes, nursing documentation and medication records. An effective handover is vital in ensuring all essential patient information is received by the nurse of the oncoming shift, allowing for the continuity of patient care and patient safety.^13,14 The inconsistencies in local prac-tice have resulted in some nurses spending a longer time in clinical handovers. These may imply a lack or misuse of time in planning patient care. Patients’ activities are delayed when the two nurses are spend-ing more time in handing over patient information and treatments. At the hospital, there were 13 medi-cation-related incidents (June 2016 to December 2016) reported due to inconsistencies in the current handover process.

The Nursing Clinical Handover Evidence Sum-mary¹⁵ retrieved from the Joanna Briggs Institute evidence-based practice database states that:

Despite advances in technology and nursing prac-tice, handovers are still seen as essential to a patient’s continuity of care and are recom-mended. (Grade B)

Handovers should include verbal (face-to-face) communication. (Grade B)

Standardized documentation (i.e. care plans, standardized handover forms, operating proto-cols) is recommended for use during the hand-over process. (Grade B)

Detailed observations and any relevant patient history are recommended in the handover pro-cess. (Grade B)

Transfer of responsibility of a patient from one nurse/shift to another nurse/shift should occur during the handover process. (Grade B)

The Joanna Briggs Institute introduced Grades of Recommendation to guide healthcare professionals to make decisions when implementing evidence in clinical practice. Grade A signifies a strong recommendation of

JBI Database of Systematic Reviews and Implementation Reports                 2019 THE JOANNA BRIGGS INSTITUTE             1004

©2019 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT

the evidence to be adopted in the clinical context, while Grade B suggests that the evidence is of lower quality but may still be recommended for use in the clinical setting, with careful consideration by appropriate healthcare expertise when used in the clinical setting.¹⁵

The above constitutes evidence related to best practice and was therefore adopted to improve the clinical handover process during shift handovers.

1. Wong et al.

size calculation was done according to the recom-mendation from the Joint Commission Interna-tional, whereby a sample of 33 nurses is adequate

when the total number of nurses in three wards ranges from 30 to 100.^18,19 The inclusion criteria

were RNs working in the morning shift conducting clinical handovers with the RNs from the oncoming shift at 1pm.

Aims and objectives

The aim of this project was to assess compliance with the evidence-based criteria regarding clinical hand-overs among RNs in three adult surgical wards in a Singapore tertiary hospital.

The specific aims were:

1. To improve RNs’ compliance with evidence-based best practice criteria regarding nursing clinical handovers to more than 80%.

1. To improve knowledge on nursing clinical handover best practice among RNs.

• To reduce medication errors arising from inef-fective handovers by 80%.

1. To reduce the time taken for handovers through a structured handover process.

Methods

Design

The pre-implementation and post-implementation audits used the Joanna Briggs Institute, Practical Application of Clinical Evidence System (JBI PACES) and Getting Research into Practice (GRiP) audit and feedback online tool. The objective was to improve nursing clinical handover practices while utilizing the best available evidence.¹⁶ During GRiP, the project team incorporated the cause-and-effect diagram, also known as the Ishikawa diagram, to identify, analyze and solve problems in clinical handover practice.¹⁷ This evidence-based quality improvement project was carried out in a Singapore tertiary hospital, specifically within three general surgical wards, each with 40 to 45 beds. This project was implemented in three phases over 11 months, from January 2017 to November 2017.

Sample/participants

The project was conducted in three inpatient general surgical wards of the hospital. The audit employed the convenience sampling method, and 33 RNs working in these wards were audited. The sample

Phase 1: Stakeholder engagement (or team establishment) and the baseline audit

The project team comprised six RNs, with two RNs from each ward, in addition to three nurse clinicians and a senior nurse educator. One of the nurse clini-cians was the project leader and an RN from each ward were co-leaders. The project leader and co-leaders, together with the other two nurse clinicians and a senior nurse educator, were responsible for the conceptualization of the project, and planning and communicating the project to the relevant stake-holders. In addition, they trained the team members on data collection, data analysis, sharing of results and supervision of project implementation. The team members were responsible for collecting base-line and follow-up audit data, acting as resource persons to their ward staff.

In spite of their busy work schedules, the team members communicated with each other regularly via electronic mail and, messaging platforms such as ‘‘WhatsApp’’, and attended meetings, discussing the auditing process and any challenges they encoun-tered.

The stakeholders included all bedside nurses, nurse managers, nurse clinicians and nurse educators from the three participating wards. The co-leaders engaged their respective ward bedside nurses to be their team members who were responsible for initi-ating the project in the ward, providing education and collecting data. The team members together with the co-leaders led the change in the ward and took ownership of the project. The nurse managers were responsible for supporting the change. The nurse clinicians and nurse educators provided feed-back and advice throughout the project planning, implementation and maintenance phases. They also facilitated discussions between team members. The project was endorsed by the assistant director of nursing. All stakeholders played a role in the project and were informed about the project plan.

JBI Database of Systematic Reviews and Implementation Reports                 2019 THE JOANNA BRIGGS INSTITUTE             1005

©2019 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT

Audit tool

A clinical handover audit tool was developed by the team, according to JBI’s best practice recommenda-tions.¹⁵ The audit criteria from the JBI PACES were selected for conducting the pre- and post-implemen-tation audits.¹⁶ The audit criteria were generated from a JBI evidence summary on Nursing Clinical Hand-over and among the seven audit criteria, four were selected based on their relevance to the project.¹⁶ In addition, the components of the audit tool were based on the hospital’s handover recipe card (Table 1).

The following were the audit criteria and compli-ance measurement:

Criterion 1: Verbal (face-to-face) communication has occurred. This was considered fulfilled when verbal face-to-face communication occurred during the nursing clinical handover.

Criterion 2: Standardized documentation has been used. This was considered fulfilled when the preceding nurse and oncoming shift nurse checked all inpatient hard copy and electronic charts during clinical handovers. This ensured all charts (medication chart, intake-output chart, clinical charts, etc.) would be updated, available

Table 1: Data collection tool – clinical handover

1. Wong et al.

and reviewed during clinical handovers by the nurses for continuity of nursing care.

Criterion 3: Relevant history of the patient has been stated. This was considered fulfilled when preceding shift nurses handed over the relevant history of the patients, such as their admission and current notes, emergency notes, transfer or discharge notes, and treatment plan and orders.

Criterion 4: Detailed observations of the patient have been stated. This was considered fulfilled when preceding shift nurses handed over the observations (Assessment, Problem, Goals, Inter-vention, Evaluation) of their patients that had been documented in the nursing notes and infor-mation list during the shift.

Data collection: Conducting the pre-implementation audit

Prior to pre-implementation, the ward nurses were informed about the time period of the audit. The pre-implementation audit was conducted in March 2017 in all three wards to obtain a total sample size of 33 RNs. The audit was conducted over three weeks, from Monday to Friday, during the afternoon shift

JBI Database of Systematic Reviews and Implementation Reports                 2019 THE JOANNA BRIGGS INSTITUTE             1006

©2019 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT

handovers at 1pm daily. The audit involved observ-ing the RN’s participation process during the shift handover and the information handed over to the oncoming shift nurse, based on the audit criteria in the hardcopy clinical audit form. The cases were divided into two different categories: i) first hand-over (oncoming shift RN had no prior knowledge of the patient and would require more time for handing over), and ii) not the first handover (oncoming shift RN was familiar with the patient condition, thus less time for handing over). The number of handovers and the patient’s length of stay were also tracked. The amount of time each RN spent on handovers depended on the number of patients admitted to the ward during the audit. Interruptions were indicated if these happened during handovers and were included in the time taken to complete the handover. A time tracker served to track the time taken for handovers per patient. Data were then entered into JBI PACES.¹⁶ The audit results were analyzed against the four criteria.

Phase 2: Design and implementation of strategies to improve practice (GRiP)

Following the completion of the baseline audit, the project team shared the audit results with nurses from all three wards. They then organized a GRiP session with three ward nurses to examine problems or barriers, utilize the best available evidence to support best practice, and develop implementation plans to overcome the identified barriers. During the session, the root cause analysis approach was incor-porated and conducted using the cause-and-effect diagram to identify, analyze and strategize how to improve clinical handover practice.¹⁷

Phase 3: Follow-up audit

The post-implementation audit was conducted to evaluate the level of improvement after the imple-mentation strategies and whether the nurses com-plied with the best practice. A post-implementation audit was repeated six months after the implemen-tation, in November 2017, to compare compliance with the clinical handover process. The same sample size (n ¼ 33) of nurses was audited in the three participating wards. The post-implementation audit was carried out in the same way as the pre-implementation audit. The time tracker was used again to track if there were differences in time between pre- and post-implementation.

1. Wong et al.

Ethical considerations

This project was conducted in accordance with the hospital’s quality improvement policy, hence no formal ethical approval was required from the ethics board. During the auditing process, no identifying information of the RNs audited was documented to ensure confidentiality. Patients’ personal informa-tion such as name, identifying number and diagnosis was not documented. No funding was received for this project.

Data analysis

Data were analyzed using the software SPSS version 21.0 (IBM Corp., Armonk, New York). The Fisher exact test was used to analyze categorical variables between the two audit periods. A p value of less than 0.05 was considered statistically significant.

Results

Phase 1: Baseline audit

The pre-implementation audit (n ¼ 33) revealed that criterion 1, verbal face-to-face handovers, occurred 100% of the time. Criterion 2, handovers of the standardized set of documentation, had a compli-ance rate of 0% (Fig. 1). In order to meet this criterion, the RN would have to hand over the inpatient medication order, hardcopy clinical charts, and all other electronic clinical charts, when necessary. When any one of these criteria was not met, the RN was considered to have failed the compliance required for handing over a standardized set of documentation. The compliance rate for detailed observations of patients stood at 72.7% (criterion 4). For criterion 3, 93.9% of the RNs from the preceding shift handed over the patient’s relevant history, reasons for admission, treatment plan and orders to the oncoming shift nurses. In order to meet audit criterion 4, the RN would have to hand over nursing care plans, daily nursing notes, an informa-tion list that indicated follow-up treatment orders from physicians and discharge plans, where neces-sary. Likewise, if any one of these criteria was not handed over, the RN was deemed to have failed in complying with handover standards. The total num-ber of handovers conducted were 88 and the hand-over timing was an average of 8.44 minutes per patient. The average length of stay for this group of patients was 12.84 days. Interruption occurred in 98% of the handovers.

JBI Database of Systematic Reviews and Implementation Reports                 2019 THE JOANNA BRIGGS INSTITUTE             1007

©2019 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT                                                                                                                            X. Wong et al.

Criteria legend

1. Verbal (face-to-face) communication has occurred. (33 of 33 samples taken)

2. Standardized documentation has been used. (33 of 33 samples taken)

3. Relevant history of the patient has been stated. (33 of 33 samples taken)

4. Detailed observations of the patient have been stated. (33 of 33 samples taken

Figure 1: Compliance with the best practice for clinical handover audit criteria at baseline audit (n ¼ 33)

Phase 2: Strategies for Getting Research into Practice (GRiP)

During the GRiP session with the three ward nurses, a problem that had emerged was RNs’ inconsistency in the clinical handover process (Fig. 2). A review session was arranged with a few nurses from the three par-ticipating wards to target the identified non-

compliance results. This was complemented with a paper survey for RNs (n ¼ 60) to highlight issues they faced with handing over. Consequently, the root causes of the non-compliance were identified and action plans were derived from the participants.

The GRiP matrix displayed in Table 2 outlines three root causes that were identified, two of which

Inconsistent

clinical nursing

handover

Registered nurses unsure

of process

No one to help cover the cubicle

Mulll bells

Figure 2: Root cause analysis of clinical handover problems, based on the cause and effect Fishbone Diagram³⁴

JBI Database of Systematic Reviews and Implementation Reports                 2019 THE JOANNA BRIGGS INSTITUTE             1008

©2019 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT                                                                                                                            X. Wong et al.

Table 2: Getting Research into Practice matrix

pertained to inconsistencies in handovers (Table 2). The first cause was failure to recognize the impor-tance of a proper handover. The second cause was poor understanding of the handover recipe card’s contents. The third cause concerned multiple dis-ruptions during handovers, hence the root cause was identified as inadequate coverage during handovers. The strategies identified by the project team and stakeholders for implementation included a teaching video and PowerPoint presentation slides developed by the project team, an improved structured and standardized handover process, visual cues (see Appendix I) and adequate human resource coverage during handovers.[unique_solution]

The implementation plan was announced to the wards during a roll call to ensure that at least 70% of the nurses were informed about the project imple-mentation. Nurses were shown a video on the hand-over. The video was also uploaded on ‘‘MeC’’, an online platform for nurses to access announcements. This targeted those who could not attend the roll call. During the implementation, regular reminders were given to nurses during the roll call and nurses encouraged to give their feedback.

During the initial implementation phase, the proj-ect team introduced the SBAR to nurses during the shift handover. The action plan was then sent to all three wards on the same day in May 2017. The

action plan, which was developed during the GRiP session, included a structured handover process to ensure adherence to the handover process. The SBAR handover format was adopted from a hand-over checklist to guide communication of patient

information between the preceding and oncoming nurses.^20,21 The purpose of the SBAR was to

improve communication of patient care information and safety of patient care in the healthcare organi-zation. The SBAR handover format also ensured the

accuracy, clarity and effectiveness of the communi-cation.^20,21 The teaching video was used as a visual

aid and learning tool for executing the clinical hand-over using SBAR. The video and presentation of the project was also presented by project team members during roll call to achieve more than 50% awareness the project.

Visual cues were put up on the computers used during handovers. Desktop wallpaper featured the hospital handover recipe card, highlighting how to use the SBAR and the frequently missed components of handover, i.e. patient and family education docu-ments and clinical charts. This helped to remind nurses of particular processes usually left out during handovers. Finally, the project team discussed with ward nursing leaders about adequate coverage dur-ing clinical handovers. Towards this end, enrolled nurses engaged in the project team would lead other

JBI Database of Systematic Reviews and Implementation Reports                 2019 THE JOANNA BRIGGS INSTITUTE             1009

©2019 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT

enrolled nurses to avoid rescheduling their work around the shift handovers and be available in the nursing cubicles whenever patients requested for assistance.

Phase 3: Follow-up audit

A repeat audit using the same audit tool was conducted six months post-implementation. Hand-over with standardized documentation (criterion 2) improved from 0% to 21.0% (X² ¼ 12.19, p ¼ 0.005). Handover with detailed observations of patients (criterion 4) improved from 72.7% to 87.9% (X² ¼ 2.44, p ¼ 0.215), while handovers of patients’

1. Wong et al.

relevant history (criterion 3) improved slightly from 93.9% to 97.0% (X² ¼ .35, p ¼ 1.000). Verbal face-to-face handover compliance (criterion 1) was main-tained at 100% (Table 3) (Fig. 3).

At the follow-up audit, the total number of hand-overs conducted was 120, and the time taken for handovers fell to an average of 8.24 minutes per patient. The average length of stay was 17.57 days. Interruption occurred in 84.2% of the handovers. In addition, the incidence of medication errors related to handovers decreased by 73.68%, from 19 inci-dences (pre-implementation) to five (post-implemen-tation) over six months (Fig. 4).

Table 3: Pre-implementation and post-implementation audit results

Nursing problems (assessment, prob-lem, goals, intervention, evaluation)

Nursing additional notes Information list

• the total number audited; #Y: number complied with criteria; %Y: percentage complied with criteria, statistical significance set at P < 0.05.

JBI Database of Systematic Reviews and Implementation Reports                 2019 THE JOANNA BRIGGS INSTITUTE             1010

©2019 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT                                                                                                                            X. Wong et al.

Criteria legend

1. Verbal (face-to-face) communication has occurred. (33 of 33 samples taken)

2. Standardized documentation has been used. (33 of 33 samples taken)

3. Relevant history of the patient has been stated. (33 of 33 samples taken)

4. Detailed observations of the patient have been stated. (33 of 33 samples taken

Figure 3: Compliance with the best practice for clinical handover audit criteria at baseline audit and follow-up cycle (n ¼ 33)

Figure 4: Reduction of medication error incidences post implementation of best practice

Discussion

This evidence-based implementation project aimed to improve the quality of RN-to-RN clinical hand-overs in the general surgical wards of a Singapore tertiary hospital. The project’s results revealed an improvement in information being handed over from one shift of nurses to the next. The results also revealed that the implementation of strategies reduced interruptions during clinical handovers. The increase in patients’ length of stay might suggest

that the nurses were familiar with patients’ condition and management, but the difference in the length of time nurses took to perform a clinical handover for each patient was marginal between the baseline and follow-up audits.

During clinical handovers, verbal face-to-face communication occurred and was sustained during the project period. The preceding shift nurses used standardized documentation such as patients’ charts for medication, fluid balance, vital signs

JBI Database of Systematic Reviews and Implementation Reports                 2019 THE JOANNA BRIGGS INSTITUTE             1011

©2019 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT

and other relevant charts to hand over to the oncom-ing shift nurses. A significant improvement was reported in relation to stating relevant patient infor-mation. The information included but was not lim-ited to details such as reason for admission, transfer history and treatment plans, which were essential in providing safe, effective and continuity of patient care.

Verbal and face-to-face clinical handovers

Verbal face-to-face handovers are the best method of handover for bedside handovers.⁹ This type of hand-overs has been a consistent practice throughout the hospital, and it is likely that nurses recognize this practice as one that is mandated by the hospital, thus complying with it. Currently, the hospital does not offer an alternative to face-to-face handovers. Hence, nurses are naturally compliant with this sole method of handover. Verbal handovers ensure that nurses systematically transfer critical patient infor-mation and nursing responsibilities to the oncoming shift. During these sessions, nurses take advantage of the opportunity to discuss, problem-solve, and com-municate patient treatment plans and concerns. Doing so leads to effective teamwork and a positive working environment.²²

The challenges nurses faced during clinical hand-overs were mainly distractions from human factors such as phone calls, healthcare professionals, call bells, monitor alarms, etc. These situations resulted in more time spent during the clinical handovers.²³ Distractions tend to influence the accuracy of infor-mation handed over to nurses. To prevent distrac-tions, the ward nurses have ensured adequate human resources coverage during clinical handovers, hence the number of interruptions decreased at the follow-up audit. However, one study reported that nurses were able to remain focused and concentrate during verbal clinical handovers even with such distractions.²²

Nurses’ clinical handovers using standardized documentation improved from 0% at the pre-implementation audit to 21.0% ( p ¼ .005) at the post-implementation audit. These results indicated that more effort would be needed to ensure the nurses adhere to the best practice of reviewing the patients’ charts together during clinical handovers. Patient safety in healthcare settings is critical, and an important approach is through documents such as bedside charts.²⁴

1. Wong et al.

According to the National Health Service Insti-tute for Innovation and Improvement, the SBAR format organizes information for the speaker to convey information succinctly and effectively, and in a meaningful manner. It also promotes adequate assessment of patients in order for critical informa-tion to be handed over. Such a structured handover ensures effective and meaningful handovers between nurses.⁶ There was a significant improvement in the the use of standardized documentation and stating of patients’ history. The implementation of such a structured handover indicates the potential for empowering nurses to conduct a handover with a good, clear purpose.²⁵ Improvements in handover consistency can also lead to safer care, as seen from the reduction in medication error post-implementa-tion.²⁶

Adherence to SBAR through visual cues and an educational video

An educational video and visual cues served as useful educational tools to teach nurses how to follow SBAR. General ward nurses spend most of their time at the bedside to provide care to patients, so it is

important for nurses to effectively communicate patient care plans to the oncoming shift’s nurses.^27,28

Using the SBAR, shift clinical handover reports improved among the nurses and clinicians.²⁷ One study conducted in a medical-surgical unit reported that SBAR shortened the handover process and enabled nurses to be more focused and efficient in communication, and improved the quality of infor-mation provided to oncoming shift nurses.²⁷

Nurses initially experienced difficulty using the SBAR because it was not part of their handover routine. After they became more familiar with the guidelines, they found SBAR to be more efficient although actual real timing did not improve based on the time tracker. However, the baseline and follow-up audit results found a slight difference between the clinical handover time. Informal feedback from nurses indicated that they preferred their original verbal handover method if and when sufficient time allowed. Nurses felt that they could hand over more patient information to the oncoming shift via verbal handovers. The traditional method of handovers may take longer and convey less purposeful infor-mation than a focused structured handover.²⁹

A review reported that videos are useful, relevant and frequently used as an instructional strategy to

JBI Database of Systematic Reviews and Implementation Reports                 2019 THE JOANNA BRIGGS INSTITUTE             1012

©2019 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT

clinical skills education.³⁰ Using videos as a teaching strategy permits the simulated clinical handover to be demonstrated in a visual, structured and orga-nized manner to ward staff nurses. The learning outcome is effective, improving learners’ confidence and satisfaction. Nurses have the flexibility to decide when to watch the video, and they may want to watch the video repeatedly.³⁰

Charts, documentation and electronic clinical documentation system

While the clinical documentation system has been rolled out throughout the hospital since 2015, cer-tain types of documentation are still being generated in paper form. During the project implementation period, patients’ vital signs, capillary blood glucose monitoring, fluid and oral intake, etc., were docu-mented on paper. During the clinical handovers, inconsistencies were evident among staff nurses when these charts had to be checked. Paper docu-ments were the least handed over information during this study. Results of the post-implementation audit revealed that further improvements were required for these nurses to adhere to when handing over these charts. After the post-implementation audit, the three participating wards commenced electronic nursing documentation for patients’ vital signs observations, fluid and oral intake, etc.

Electronic documentation of patient records is relevant, meaningful and useful and improves the quality of care in the hospital. Nurses’ perceptions

of electronic documentation are positive, so their willingness to adopt it is at a high level.^31,32

The nurses’ acceptance might be influenced by the environment, its usability, less redundancy in doc-umenting patients’ information, and nurses’ famil-iarity with the documentation software.^31,32 When nurses believe that electronic documents are essen-tial to patient care and easy to access, they will adhere to this best practice.³³ We expect an increase in the volume of various electronic patient charts being communicated during the clinical handovers to oncoming shift nurses. Therefore, it is paramount to improve communication methods during handovers.

Limitations

This project experienced several limitations. Firstly, this project was implemented over a period of only six months. Given the nature of the project

1. Wong et al.

methodology, the project was limited to three surgical wards and a small sample size. A longer time frame might have produced more substantial improvement findings. Lastly, feedback was obtained from only a small population of the total number of ward nurses.

Conclusion

The results of the audits demonstrated an improve-ment in nurses’ compliance with best practice during clinical handovers. The utilization and provision of relevant resources achieved an improvement in reg-istered nurses’ knowledge of clinical handover prac-tices, and there was a slight difference in the clinical handover time between the baseline and follow-up audits. The comprehensive clinical handover prac-tice reduced medication errors that had occurred previously due to inconsistencies in handover prac-tices. Nurse leaders and ward nurses will play an important role in sustaining best practice. The recommended evidence-based practice has been included in the hospital-wide handover project, and the project team co-leader has been engaged as part of the hospital workgroup.

Acknowledgments

The authors would like to thank all the nursing leaders and staff from the participating wards who contributed to the success of this project.

References

1. Chaboyer W, McMurray A, Johnson J, Hardy L, Wallis M, Chu FYS. Bedside handover: quality improvement strategy to ‘‘transform care at the bedside’’. J Nurs Care Qual 2009;24(2):136 –42.

2. Redley B, Waugh R. Mixed methods evaluation of a quality improvement and audit tool for nurse-to-nurse bedside clini-cal handover in ward settings. Appl Nurs Res 2018;40:80–9.

3. Smeulers M, Lucas C, Vermeulen H. Effectiveness of differ-ent nursing handover styles for ensuring continuity of information in hospitalized patients. Cochrane Database Syst Rev 2014;(6):CD009979.

4. Scovell S. Role of the nurse-to-nurse handover in patient care. Nurs Stand 2010;24(20):35 –9.

5. Meum T, Ellingsen G. ’Sound of silence’ – changing from an oral to a computer-mediated handover. Behav Inform Technol 2011;30(4):479 –88.

6. Cowan D, Brunero S, Luo X, Bilton D, Lamont S. Developing a guideline for structured content and process in mental health nursing handover. Int J Ment Health Nurs 2018; 27(1):429 –39.

JBI Database of Systematic Reviews and Implementation Reports                 2019 THE JOANNA BRIGGS INSTITUTE             1013

©2019 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT

7. Wentworth L, Diggins J, Bartel D, Johnson M, Hale J, Gaines K. SBAR: Electronic Handoff Tool for Noncomplicated Pro-cedural Patients. J Nurs Care Qual 2012;27(2):125 – 31.

8. Johnson M, Sanchez P, Zheng C. Reducing Patient Clinical Management Errors Using Structured Content and Electronic Nursing Handover. J Nurs Care Qual 2016;31(3):245–53.

9. Drach-Zahavy A, Goldblatt H, Maizel A. Between standardisa-tion and resilience: nurses’ emergent risk management strat-egies during handovers. J Clin Nurs 2015;24(3–4):592–601.

10. Milesky JL, Baptiste DL, Shelton BK. An observational study of patient handover communications among nurses on an oncology critical care unit. Contemp Nurse 2018;54(1):77–87.

11. Groves PS, Bunch JL, Cram E, Farag A, Manges K, Perkhoun-kova Y, et al. Priming Patient Safety Through Nursing Handoff Communication: A Simulation Pilot Study. West J Nurs Res 2017;39(11):1394 –411.

12. Riesenberg LA, Leisch J, Cunningham JM. Nursing handoffs: a systematic review of the literature. Am J Nurs 2010; 110(4):24 –34.

13. Kasinathan S, Ang E, Lee J. Patient handover in the oncology setting: an evidence utilisation project. Int J Evid Based Healthc 2012;10(4):369 –76.

14. Street M, Eustace P, Livingston PM, Craike MJ, Kent B, Patterson D. Communication at the bedside to enhance patient care: A survey of nurses’ experience and perspective of handover. Int J Nurs Pract 2011;17(2):133 –40.

15. Slade S. Evidence Summary. Nursing: Clinical Handover. The Joanna Briggs Institute EBP Database. JBI@Ovid 2018:JBI1615.
16. Joanna Briggs Institute. Joanna Briggs Institute Practice Application of Clinical Evidence System (PACES) [Internet]. Adelaide: Joanna Briggs Institute; 2018; [cited 19 Mar 2018]. Available from: http://paces.jbiconnectplus.org/.

17. Hewitt-Taylor J. Identifying, analysing and solving problems in practice. Nurs Stand 2012;26(40):35 –41.

18. Larrabee JH. Nurse to nurse: Evidence-based practice: McGraw-Hill Medical; 2009.

19. The Joint Commission Organizations. Specifications Manual for Joint Commission National Quality Measures v2017B. [internet]. [cited Aug 19, 2018]. https://manual.jointcom-mission.org/releases/TJC2018A/assets/Manual/TableOfCon-tentsTJC/TJC_v2018A.pdf.

20. Porteous JM, Stewart-Wynne EG, Connolly M, Crommelin PF. iSoBAR—a concept and handover checklist: the National Clinical Handover Initiative. Med J Aust 2009;190(11 Suppl): S152– 6.

21. Stewart KR. SBAR, Communication, and Patient Safety: An Integrated Literature Review. Medsurg Nurs 2017;26(5): 297–305.

1. Wong et al.

22. Giske T, Mela˚s SN, Einarsen KA. The art of oral handovers: A participant observational study by undergraduate students in a hospital setting. J Clin Nurs 2018;27(5 –6):e767 –75.

23. Kowitlawakul Y, Leong BS, Lua A, Aroos R, Wong JJ, Koh N, et al. Observation of handover process in an intensive care unit (ICU): barriers and quality improvement strategy. Int J Qual Health Care 2015;27(2):99– 104.

24. Wainwright C, Wright KM. Nursing clinical handover improve-ment practices among acute inpatients in a tertiary hospital in Sydney: a best practice implementation project. JBI Data-base System Rev Implement Rep 2016;14(10):263–75.

25. Bakon S, Wirihana L, Christensen M, Craft J. Nursing hand-overs: An integrative review of the different models and processes available. Int J Nurs Pract 2017;23(2):e12520.
26. NHS Institute for  Innovation  and    Safer

Care SBAR Situation Background Assessment Recom-mendation Implementation and Training Guide. 2010. [internet]. [cited Aug 19, 2018]. https://www.england.nhs. uk/improvement-hub/wp-content/uploads/sites/44/2017/ 11/SBAR-Implementation-and-Training-Guide.pdf.

27. Cornell P, Gervis MT, Yates L, Vardaman JM. Impact of SBAR on nurse shift reports and staff rounding. Medsurg Nurs 2014;23(5):334.

28. Manias E, Geddes F, Watson B, Jones D, Della P. Perspectives of clinical handover processes: a multi-site survey across different health professionals. J Clin Nurs 2016;25(1 – 2):80–91.

29. Kassean HK, Jagoo ZB. Managing change in the nursing handover from traditional to bedside handover –a case study from Mauritius. BMC Nursing 2005;4(1):1 –6.

30. Forbes H, Oprescu FI, Downer T, Phillips NM, McTier L, Lord B, et al. Use of videos to support teaching and learning of clinical skills in nursing education: a review. Nurse Educ Today 2016;42:53 –6.

31. Kaye SP. Nurses’ Attitudes Toward Meaningful Use Technol-ogies: An Integrative Review. Comput Inform Nurs 2017; 35(5):237 –47.

32. Strudwick G, McGillis Hall L. Nurse acceptance of electronic health record technology: a literature review. J Res Nurs

2015;20(7):596 –607.

´

33. Maillet E, Mathieu L, Sicotte C. Modeling factors explaining the acceptance, actual use and satisfaction of nurses using an Electronic Patient Record in acute care settings: An extension of the UTAUT. Int J Med Inform 2015;84(1):36 –47.

34. Iyer S, Stone E. Pediatric Quality Improvement in the Pre-hospital and Emergency Department Worlds: Tools and Examples to Guide Change. Clin Pediatr Emerg Med 2018;19(3):199 –205.

dx, Diagnosis; MDT, Multidisciplinary Team; RN, Registered Nurse; PMHx, Past Medical History; ED, Emergency department; eIMR, Electronic Inpatient Medication Record; APGIE, Assessment, Problem, Goal, Intervention & Evaluation; PFE, Patient and Family Education