Summary
The aim of this report is to examine the handover process of patients. The report proposes a change of the handover from the traditional office-based style to the bedside handover style. The reasons for the change of the handover style include disruptions to patient care caused by the traditional method, low quality patient care, and wastage of time during handover. The change proposed is based on NHS Institute of Innovation and Improvement guidelines. In addition, the Lewin’s change theory and SWOT analysis will be used to implement the change. It is hoped that the new method of handing over patients to oncoming nurses will reduce the time spent on handovers, the disruptions to patient care and will enhance the quality of patient care.
Introduction
The aim of this report is to discuss a change in the handover process of patients in a bone marrow transplant unit. Traditionally, the handover of patients from one nurse to another was done in the nurse office/break room through the telephone or fax machine thereby creating regular interruptions to the handover process (Watkins, 1997). In addition, the quality of information communicated by the off-going nurse to the oncoming nurse was poor, thereby increasing the opportunities for medical errors. To avoid such interruptions and medical errors, this report proposes a bedside handover process.
In this process, the handover from one nurse to the next nurse is done at the bedside of the patient. The nurses exchange reports on the patient both in written form and verbally. The main purpose of this process is to reduce the opportunities for medical errors because the nurses can clarify all the information pertaining to the patient thereby enhancing the quality of care provided to the patient (Fenton, 2006; Baker & McGowan, 2010). Bedside handover also ensures the continuity of patient care with minimal disruptions (O’Connell, MacDonald & Kelly, 2008).
This report will make use of the guidelines published by the NHS Institute for Innovation and Improvement in 2007 on how bedside handovers should be conducted and the leadership and management styles required to ensure a successful bedside handover process. In addition, the report will utilize Kurt Lewin’s Three-Stage Change Theory and a SWOT analysis tool to implement the change in the bone marrow transplant unit.
Key Factors in the Handover Process
The NHS Institute for Innovation and Improvement (2001) provides guidelines on changes in shift handover process. The guidelines highlight several steps that should be followed when implementing the change. The first step is the preparation stage which involves: deciding on who should be involved in the process, talking to the healthcare staff about the problem and their experiences, talking to patients about their experiences and worries, recording the handover process through photographs and videos, gathering complaints from patients, trust surveys and incident reports, noting the length of time a handover takes, creating guidelines on handovers and taking into consideration best practice (NHS Institute for Innovation and Improvement, 2001).
The second step in the change process is the assessment stage. The aspects that should be assessed include: the process involved in the handover (this can be achieved through the video recordings), accidents, errors and near misses, patient experience, and staff experience. The third stage is the diagnosis stage. This stage involves trying out different strategies that could address the problems experienced by both the staff and patients during the handover process (NHS Institute for Innovation and Improvement, 2001).
For instance, the team could try out a stand-up meeting during the handover to reduce the time it takes for the handover to take place. In addition, the handover could take place around the bedside of the patient where the nurses involved can discuss the report on the patient thereby reducing repetition and miscommunication. This strategy also involves the patient in the process hence the patient feels part and parcel of his care (Chaboyer, McMurray & Wallis, 2009).
After diagnosing the problems and discussing the best solutions to the problems, the next step is to plan for the new handover process. The first step in the planning stage is to create the design of the new process. The second step is to plan on how the implementation of the new design will take place. The last step is to create a ‘standard operating procedure’ which should contain all the things that should be done to make the new handover process function (NHS Institute for Innovation and Improvement, 2001).
The NHS Institute for Innovation and Improvement guidelines have been used successfully to change the manner in which some wards carry out their handover processes. For instance, Rudd (2010) conducted a study to examine the change in handover implemented by University Hospitals Coventry and Warwickshire NHS Trust. The main goal of the ward’s change in handover process was to save time that could be spent on providing care to patients.
The ward manager involved all the staff of the ward in the change process, believing that the success and sustainability of the change could only be achieved if all staff members were involved. Following the NHS guidelines, such as recording the handover process and regular evaluation of performance, the team at the ward was able to increase the amount of time spent on direct patient care by 28 percent, and to reduce the rate of sickness to a minimal level.
Using Kurt Lewin’s Change Theory to Implement Handover Change in the Bone Marrow Transplant Unit
The three-step change model was formulated by Kurt Lewin in 1951. According to Lewin, “behaviour can be seen as a dynamic balance of forces working in opposing directions,” (Marquis & Huston, 2008, p. 168). The theory has three main stages.
Unfreezing stage
According to Lewin’s three-step theory, the first step in bringing about change is known as the unfreezing stage. This implies the unfreezing or undoing of the current state or the status quo. Unfreezing is a crucial stage in defeating the limitations brought about by individual opposition and or group conformity (Marquis & Huston, 2008). There are some activities that can help in unfreezing the current situation and include: encouraging all those involved by making them ready for change, building trust and realizing for the necessity of the change, as well as playing an active role in identifying problems and discussing possible solutions with other team members (Ziegler, 2005).
Lewin’s first step of change can be used in bringing about change in the manner in which patients are handed over by the off-going nurse to the oncoming nurse. To begin with, the nurse manager, acting as the key change agent, recognizes the necessity of doing things differently so as to reduce the disruptions to patient care and the medical errors that result from inaccurate information passed from one nurse to another during the change of shift. Once the nurse manager has recognized this need, she creates awareness among the staff members and together they brainstorm for possible solutions to the problem (Meleis, 2007). Bedside handover process is proposed as the most effective handover style.
During this stage, a SWOT analysis is conducted to identify the strengths, weaknesses, opportunities and threats to the proposed change. The strengths identified include: a nursing team that is willing and motivated to change so as to improve patients’ outcomes and the working environment, and a committed leadership and management. The weakness identified is the lack of prior experience in bedside handover process.
The opportunities identified include increasing pressure from patients to be involved in their care, and the existence of guidelines on the implementation of bedside handovers as well as best practice studies on bedside handovers. The threat includes resistance from some of the nurses to adopt the newly proposed handover style claiming lack of time for meetings between the off-going and the oncoming nurses (Kassean & Jagoo, 2005).
Movement stage
The second stage in Lewin’s theory of change is referred to as the movement stage. Roussel and Swansburg (2006) argue that, “in this step, it is necessary to move the target system to a new level of equilibrium,” (p. 63). With regard to changing from the traditional handover process to the newly proposed bedside handover, the nurse manager and the team will begin the implementation of the new process. The team creates a plan of action that will be followed by the nurses and staff members involved in the handover process. The first plan of action is to improve communication between the off-going and oncoming staff members during a shift change.
Rather than communicating via the telephone and fax machine, the team will meet at the bedside of each patient fifteen minutes before the beginning of the new shift. The team members will discuss the reports prepared by the off-going team and the progress of the patient. The off-going team should also introduce the oncoming team to the patients. The aim of this plan of action is to reduce medical errors that arise from incomplete and inaccurate information pertaining to the patient (Davies & Priestly, 2006; Scovell, 2010).
This plan of action also involves the patients in their care because they can hear what is being discussed by the team and can take part in the discussion if need arises (Kerr, 2001). The second plan of action will be to hold stand-up meetings during the handovers. The aim of the stand-up meetings is to ensure the team stays focused during the handovers and to reduce the amount of time spent in handing over patients to the oncoming staff members (Webster, 1999).
The success of the proposed bedside handover process depends largely on the management and leadership styles adopted by the nurse manager. In order to ensure the effectiveness and sustainability of the proposed change, the nurse manager should utilize a participative leadership style. This style of leadership involves other members of the team in the change process. It is about having a shared vision and common goal (Baker & McGowan, 2010).
The nurse manager should hold meetings with the staff members in which she communicates the need for the change and encourages opinions from the staff members on the way forward (Romano, 2009). This leadership style is effective in motivating staff members to change the way things are done. Because the staff members are made part of the change process right from the beginning, they feel appreciated and therefore are more likely to ensure the sustainability of the change rather than when the change is pushed down their throats (Kenmore, 2008).
Refreezing stage
The third stage in Lewin’s theory of change is referred to as the refreezing stage. This stage entails incorporating the novel values into the organizational culture. Swansburg and Swansburg (1995) argue that “the purpose of refreezing is to stabilize the new equilibrium resulting from the change by balancing both the driving and restraining forces” (p. 251). One strategy that can be used to achieve sustainability of change is to reinforce new behaviours and make them part and parcel of the organizational culture through both formal and informal means, for instance, through legislations, processes and organization’s policies.
One important element of the refreezing stage is evaluation of the effectiveness of the new handover process. In particular, once the change has been implemented in an organization, the organization needs to conduct evaluation or assessment to determine the success or failure of the change. Evaluation can be done monthly, quarterly, semi-annually or annually, depending on the needs of the clients, staff and organization. The importance of evaluation is that it can bring to light the challenges facing the change implementers as well as the strengths and weaknesses of the proposed change. This can help the unit to revise the proposed change if and when need arises (Ziegler, 2005).
The nurse manager of the bone marrow transplant unit will carry out evaluation tests on a monthly basis. This will be done by collecting data on the number of adverse events that occur in the unit such as medical errors and near misses. Other indicators will include: the length of stay in the ward (this will act as a proxy for the quality of care provided to the patients), the satisfaction of the staff members, and the amount of time spent on the handing over process. The data will be collected through surveys, patients’ records and progress reports (Maurer & Smith, 2005).
Conclusion
Handovers are a critical element of the nursing practice. Handovers play important functions such as passing on important patient information from one nurse to another. Thus said, the manner in which the handover is done has a great impact on the quality of care provided to patients. Handovers can either minimise or enhance the opportunities for commission of medical errors through incomplete or inaccurate information.
This report has proposed a change of handover style from the traditional office handover to bedside handover. The change has been proposed in accordance with the guidelines published by the NHS Institute for Innovation and Improvement. It is believed that the bedside handover process will reduce medical errors and enhance the quality of patient care through comprehensive communication of patient information between the nurses involved in the handover process. The new style will also reduce the time spent in the handing over process and increase the amount of time spent on providing care to each patient.
Recommendation
The effectiveness of the proposed change in handover from traditional to bedside handover will be determined by the results of the evaluation process. Such effectiveness will be evidenced by positive patient and staff outcomes such as shorter hospital stays, shorter time spent in the handover process, staff satisfaction with the new handover process, and a reduction in the number of adverse events such as near misses and medical errors. However, if the evaluation shows a negative impact (or no improvement at all), the nurse manager should re-assess the proposed change and identify the weaknesses and challenges. The proposed change should then be re-designed to address the weaknesses and challenges.
References
Baker, S. & McGowan, N., 2010. Bedside shift report improves patient safety and nurse accountability. Journal of Emergency Nursing, 36, 355-358.
Chaboyer, W. McMurray, A. & Wallis, M., 2009. Bedside nursing handover: A case study. International Journal of Nursing Practice, 16, pp. 27-34.
Davies, S. & Priestly M., 2006. A reflective evaluation of patient handover practices. Nursing Standard, 20(21), pp. 49-52.
Fenton, W., 2006. Developing a guide to improve the quality of nurses’ handover. Nursing Older People, 18(11), pp. 32-36.
Kassean, H. & Jagoo, Z., 2005. Managing change in the nursing handover from traditional to bedside handover – a case study from Mauritius. Biomed Central Nursing, 4(1), pp. 1-6.
Kenmore, P., 2008. Exploring leadership styles. Nursing Management, 15(1), 24-16.
Kerr, M., 2001. A qualitative study of shift handover practice and function from a socio-technical perspective. Journal of Advanced Nursing, 37 (2), 125-134.
Marquis, B. & Huston, C., 2008. Leadership roles and management functions in nursing theory and application. Philadelphia, PA: Lippincott Williams & Wilkins.
Maurer, F. & Smith, C., 2005. Community/public health nursing practice: health for families and populations. London: Elsevier Health Sciences.
Meleis, A., 2007. Theoretical nursing: development and progress. Philadelphia, PA: Lippincott Williams & Wilkins.
NHS Institute for Innovation and Improvement, 2001. Releasing time to care: The productive ward shift handovers. Nottingham: NHS Institute for Innovation and Improvement.
O’Connell, B. MacDonald, K. & Kelly, C., 2008. Nursing handover: It’s time for a change. Contemporary Nurse, 30(1), pp. 1-11.
Romano, A., 2009. The great divide: The culture of bedside nurses and nurse managers. Nurse Leader, 47-50.
Roussel, L. & Swansburg, R., 2006. Management and leadership for nurse administrators. Boston, MA: Jones & Bartlett Learning.
Rudd, S., 2010. Implementing the productive ward management programme. Nursing Standard, 24(31), pp. 45-48.
Scovell, S., 2010. Role of the nurse-to-nurse handover in patient care. Nursing Standard, 14(20), pp. 35-39.
Swansburg, R. & Swansburg, L., 1995. Nursing staff development: a component of human resource development. Boston, MA: Jones & Bartlett Learning.
Watkins, S., 1997. Introducing bedside handover reports. Professional Nurse, 12(4), 270-273.
Webster, J., 1999. Practitioner-centered research: an evaluation of the implementation of the bedside handover. Journal of Advanced Nursing, 30(6), 1375-1382.
Ziegler, S., 2005. Theory-directed nursing practice. New York, NY: Springer Publishing Company, Inc.