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Handover of information about a patient from one nurse to another at the change of shift is crucial. It ensures that critical patient care remains continuous and facilitates the transfer of responsibility for, and accountability to, the patient (Jeffcott et al., 2009). In addition to a patient handover, nurses working in the paediatric intensive care (PIC) also receive an overview of the clinical situation of the whole unit, a unit handover. Information contained in this handover is diverse but commonly serves an organisational and administrative purpose.
The effectiveness and efficiency of all handovers is vital since poor handover practice has been identified to potentially result in inadequate or unsafe nursing care (Mascioli et al., 2009, Johnson & Barach, 2009). Published literature about handover specifically in PIC is still limited and very little discusses the unit handover, despite it, anecdotally, occurring in Paediatric Intensive Care Units (PICU) worldwide.
Recognising the “perilous time” that handover can be to patients (BMA, 2004), the World Health Organisation (WHO) called for a standardisation of handover practice (WHO, 2007). This was succeeded by a wealth of published articles describing implemented standardisation strategies; some more effective than others, and many acknowledging the challenge of changing this almost ritualistic nursing practice.
The need to optimise the efficiency and effectiveness of unit handover in the PICU became evident from a larger study into all nursing handover practices conducted in the PICU at Red Cross War Memorial Children’s Hospital in Cape Town, South Africa. This presentation will report on this arm of the study.
Methods:
A participative action research approach was applied. The sample consisted of nurses from the study setting, together with the researcher, forming a core participant group. Action research cycles of assessment/reflection, planning, action and observation were used to navigate through five phases of diagnosis, planning, implementation, evaluation and learning (Heale, 2003).
Focus groups followed by a rapid appraisal, consisting of observations, a questionnaire and a document review, first facilitated the making of the existing practice visible. This ‘diagnosis’ led to the identification of the features of practice that required optimisation, and enabled the will to make a change. Identification, implementation and evaluation of strategies appropriate to the setting were then possible.
Results:
The initial diagnosis phase identified that the existing unit handover consisted of the unit manager calling half of the nursing team to a face-to-face ‘huddle’ in an empty bed space to convey information about current patient situation, clinical/admin messages and upcoming events. It was found to require optimisation in four ways; attendance of all staff, regularity of occurrence across all shifts, compliance with expected start time and minimisation of interruptions to morning care activities.
Technology, a common handover standardisation strategy (Riesenberg et al.,2010), was proposed as a solution. A trial of an electronic handover presentation, scrolling continuously in the staff tea room was implemented, and then evaluated through a questionnaire and focus group. Data revealed support from participants for continued implementation of the electronic presentation, in particular, those on the night shift indicated a considerable increase in their access to information. Concerns arose from the data about the decreased amount of face-to-face team interaction.
Conclusion:
Action research, as a methodology, was very effective in this setting in enabling the will and generating the ideas for and action towards a change in practice. However, the outcome of the study highlighted a challenge to the use of technology in nursing. Following feedback of the outcome of the evaluation to the PIC nursing management team, the team proposed that the electronic handover should run alongside the existing face-to-face unit handover. This proposal highlights the previously unappreciated real need for nurses to engage and communicate in a person-centred manner, rather than by use of technology, a finding which is useful to understand when researcher clinicians encounter resistance to other proposed technological changes in practice.