There is substantial research evidence that miscommunication results in poor outcomes, and rigorous study designs are required to improve handover (Robertson, Morgan, Bird, Catchpole, & McCulloch, 2014). In fact, 60-80% of communication failures (including handover) contribute to clinical incidents (The Joint Commission, 2013). Intra-hospital handover, or within hospital handover, of patients, are high risk scenarios. These handovers are risky because of the co-ordination of differing health professional from differing contexts, organisational pressures and logistical arrangements of transferring patients (Gardiner, Marshall, & Gillespie, 2015). There is little value devising interventions for improving clinical outcomes in hospitals, without sufficiently understanding the problems faced by staff (French et al., 2012). Thus the aim of this study is to identify the barriers and enablers to effective emergency department (ED) to inpatient unit (IPU) nursing handovers.
Methods:
One approach to designing and implementing interventions that is likely to be effective and sustainable in practice is a knowledge translation (KT) approach (Canadian Institutes of Health Research, 2015). Integrated KT has a strong focus on involving end users in all phases of research, including problem assessment (Canadian Institutes of Health Research, 2015). Thus we undertook a problem assessment with 50 nurses working in ED and IPUs. A semi-structured interview guide was used to explore nurses’ perceived barriers and enablers to effective intra-hospital handover. The interview guide was guided by the Theoretical Domains Framework (TDF). The TDF combines many overlapping behavioural theories (Cane, O’Connor, & Michie, 2012), providing a succinct and validated list of 14 domains to guide intervention development including; knowledge; skills; role identity; belief about capability; optimism; belief about consequences; reinforcement; intentions; goals; memory, attention and decision processes; environmental context and resources; social influence; emotion and behavioural regulation (Cane et al., 2012). Ten focus group interviews were conducted and audio-recorded, with two researchers were present. The size of each group ranged from 4-8 participants, and data saturation was achieved.
Initial analysis of data has occurred. Once interviews are transcribed, a formal barriers analysis will be conducted. Deductive content analysis will occur on transcribed interviews (Elo & Kyngäs, 2008). A categorisation matrix will be designed using the 14 domains of the TDF, and interview data will be coded according to the dimensions in the matrix (Elo & Kyngäs, 2008).
Results:
‘Belief about capabilities’ and ‘skills’ were viewed as enablers, as nurses perceived they had the ability to provide high quality handover. Further nurses’ ‘motivation’ to improve practice was high, and their ‘beliefs about consequences’ showed they were concerned about the handover process, and wanted to improve practice and patient safety.
The most frequent barriers discussed were ‘role identity’ and ‘knowledge’. For role identity, there were many nurses involved in the handover and transfer process. An initial handover occurred between the ED team leader and the IPU team leader, while the patient was in ED. After this handover occurred, role confusion occurred. It was unclear who should transfer the patient to the IPU (orderlies or nurses not providing direct care for the patient were often used to transfer and handover the patient to the IPU), and the role of the person transferring the patient was unclear in terms of handover content required on the IPU, given an initial handover occurred between two team leaders. Nurses in ED and IPU stated the lack of agreement on roles provided many opportunities for poor information transfer.
Both ED and IPU staff agreed that that ED staff did not have sufficient ‘knowledge’ of their patients, due to time pressures in ED and limited handover practices between ED nurses. As a result a culture of ‘chart biopsy’ occurred, where ED staff would often handover content directly from the electronic medical record, which IPU staff could also read. Thus IPU nurses were often dissatisfied as they required different information, such as tasks completed be bedside nurses and changes that had occurred to the patient.
Conclusion: Using the TDF allowed us to undertake a theory-informed problem assessment of ED to IPU handover. As a result, two improvement groups have been formed at the hospital, each addressing barriers identified (‘knowledge’ and ‘role identity’). In each group, researchers, quality improvement leaders and clinicians will continue to work together, allowing research evaluative measures to be used to test the effectiveness of strategies developed. Using a knowledge translation approach, where end-users are involved, is likely to maximise the acceptability of interventions introduced, and in turn improve clinical outcomes (Canadian Institutes of Health Research, 2015).