The primary aim of the project is to reduce the adverse
patient outcome without disturbing the continuity of care with higher quality
A clinical handover is the transfer of information, accountability
and responsibility for a patient or group of patients. A standardisation of key
principles for clinical handover will aid effective, concise and complete
communication in all clinical situations and facilitate care delivery.Traditionally
handovers have occurred in different ways and can vary depending upon the
caregivers roles, hierarchies, circumstances and traditions (Athwal, Fields
& Wagnell. 2009). Inadequate communication handovers have been identified
as the basic cause in sentinel events (Adamski, 2007; Patterson & Wears,
2010). The different unit culture and
contexts and resulting lack of collaboration and cohesion between nurses to
create increased risk for adverse events (Behara et al., 2005).
A typical handover involves the exchange of important
information such as patients engagement, medications and discharge plans from
one nurse to another. Handover is a common tradition among nurses however
standard and effective handover and information communication skills are not
taught formally taught during nursing academic education; rather nurses learn
such skills during their daily practice and form more experienced nurses.
Different countries have started to implement strategies
to reduce the working hours of healthcare professionals (Australian Medical
Association, 2006b, Australian Medical Association, 2006a, British Medical
Association. 2004). In 2004, Sexton, Chan, Elliot, Stuart & Crookes
understook a study to investigate the value and content of nurse to nurse shift
report because of criticisms related to time expenditure, content, accuracy,
and usefulness of shift report within the role of modern nursing. There were 23
handovers were audio taped in a medical ward in Sydney, Australia hospital.
Then the audio was analyzed and classified according to the location in medical
record. The results demonstrated that 84.6% of the information discussed in the
report could be found in existing documentation structures. 9.5% of time the
information was not relevant to patients care were discussed. Actual
information exchanged was not in current documentation was only 5.9%.
In 2002 Kerr, reports that there is a structured handover
method the quality of care is promoted and nurses will have a full understanding
and knowledge about the patients.
The importance of having a structured handover process
stating that it will lead to an improvement in the quality of care delivered
were discussed by Glen in 1998.
OVERVIEW OF CURRENT EVIDENCE
A study was conducted in 2011 at a hospital located in
Mashad, Iran. The population consisted of ICU nurses having bsc degree with 6
months of work experience. The study sample size was of 55 nurses. The main aim
for this study was to improve the nursing handover styles
Discourse analysis does not seem to be the choice of
method of many texts in the literature search. One discourse analysis on
nursing handover looked at anxiety in nursing practice (Evans et al., 2008).
However there are many research articles that integrate components of discourse
as language in use. Language in use can stand alone or be made significant by
the related social interaction. Many researches had shown mixed views of nurses
towards beside clinical handover. Handover is a predominant practice in
healthcare and problems such as medication errors and delays in treatment can
arise from poor communication during handover. Perceptions and experiences of
bedside clinical handover and to lay a foundation to improve future bedside
clinical handover processes. In this study i would like to explore nurses
perceptions of bedside clinical handover.
According to McNamara 1999; Interviews are particularly
useful for getting the story behind a participants experience. The interviewer can
pursue in depth information around the topic. Group interview is a semi
structured interview which involves a moderator leading a discussion between
small groups of respondents in a specific topic. An interpretive, descriptive,
qualitative research approach was used to gain an insight into nurses
understanding and their perception. Group interview with semi structured
questions were conducted with nurses. The inclusion criteria for this study
were registered nurse with one year of clinical experience in hospital, nurses
who are involed in bedside handover and nurses who had participated earlier in
bedside handover. There were mainly 7 question in the interview been conducted.
The questions were mainly based on the existing perception and knowledge of
nurses regarding their view about bedside clinical handover.
Nurses from different background were chosen for this
study. The demographic data of the nurses were also included such as their
gender, age, grade and work experience. Four groups with five nurses in each group.
The interview was held in a private room to ensure privacy. Each group were
interviewed for 30 minutes to an hour. Non verbal clues such as body language
and expressions were also taken into considerations. A member from the research
team sat in all the interview to provide guidelines. In this study nurses
described that some patients verbalized not to be involved in the clinical
handovers conducted at bedside as they would prefer to do other thing such as
rest or attend to visitors and family members.
This research has mainly focused on bedside clinical
handover importance. In this study the group of nurses were given privacy and
the information was not disclosed in front of patients and their family
members. This survey had deliberately not included patients so that the privacy
and dignity of patient shall be maintained. Apart from this the study do not
have any ethical issues as we have not particularly discussed about the medical
condition or any other topic which would effect the confidentiality of the
The participants were all from one ward of an acute
tertiary hospital and it only reflected on the perception of that clinical
area. The ward mainly received patients with higher socio economic background
and therefore the expectations regarding to participation in clinical handover
is different from other wards. Findings from quantitative study would be not
generalized to other settings.
EVALUATION OF RESULTS
A total 20 nurses participated in this interview.
Majority of the participation were 95% of female nurses with an average of 10
years of work experience. Some nurse felt that there were frequent
interruptions and distractions from the patient and surrounding because of
which the important information was missed out during handovers. They felt that
with no interruptions and distractions the handover would be holistic.
Whereas some other nurses perception was they were viewed
as unprofessional by the patients and family members while conducting nursing
handover. Nurses even felt that instead of giving handover they had to do small
task in between said by the patients and relatives. Some nurses also mentioned
that they tend to giggle and laugh during handover but they felt as if they
were exposing themselves to patients and family members and they were
susceptible to negative impressions from patients and their family members.
This provided insight into nurses perceptions of bedside
handover and the challenges faced by the nurses during bedside handover. Nurses
identified both the advantages and disadvantages of bedside clinical handover
from nurses point of view. This was illustrated by lack of consistency in the
nurses perception of bedside clinical handover.
SERVICE IMPROVEMENT PROJECT
6.1 CURRENT FINDINGS
Patient confidentiality can be compromised.
In semi private rooms there would be other patients and relatives who would
also be listening to all the confidential information of the patient in the
Request of secrecy. Some of the patients or
family members request nurses not to reveal certain information due to their
personal reasons where in this would be the most important information that
needs to be passed on to incoming nurse on shift.
Misinterpretation of information. During
bedside handover the other patients and relatives would hear the diagnosis of
this patient and they would start fearing unnecessarily and would create a
misunderstanding among other patients.
Disturbance during bedside handover. Nurses
felt that in between the handover there would be interruptions and distraction
by patient relative regarding updating the status of patient condition and
their treatment plans because they could see nurse in the room.
Time consuming. While bedside clinical
handover there would be patient involvement their doubts and questions were
inevitable thus delay the process of handover which leads to delayed patient
care and their treatment.
In order to bring the change initiated requires a
direction and power of leadership. By the work of Swansburg and Swansburg who
argued that “Transformational leaders are seen in healthcare organizations as a
commitment to excellence.” To bring about a change in a hospital setting is a
huge task as it is about the change in the attitude and behaviour of the staff
in a difficult environment in order to gain their co-operation.
The first step would be to create awareness among the
people who were going to be affected by this new improvements that would
include the staff nurses, ward managers, patients and their family members. This
would help in improving the handover system. Discussion among nurses in the
ward which will lead to more information about the new handover system.
Problems faced during handover should be brought up in the meeting by the
nurses should be taken into consideration and solved at managerial level with
better improvements and put in practice. Different communication channels to be
used such as personal contact with nurses to understand their point of view.
Initially the ward managers would act as mentor for other nurses who are been
experienced in this particular areas to encourage the nurses and support them
in their difficult situation. Time to time revising and practicing would become
an ease to put into daily habit of practice. Initially they would be supervised
by their seniors and later on once they are confident enough they can carry out
their work through self confidence.
Planning and implementation should be done very carefully
to minimize the adverse effects on the change. To deal with the conflict a
flexible and humanistic approach has to be taken in consideration. The
suggestions been put forward by the team members should be treated with respect and dignity. Feedbacks
should be constructive according to the level of performance. If the nurses
were doing really well appraisal to be given to them so that they would strive
more harder to put in their efforts as the famous proverb says “No pain No
LEADERSHIP PROCESS FOR SERVICE IMPROVEMENT
MANAGING CHANGE OF SERVICE IMPROVEMENT
For any strategy to workout it needs to be evolved. For
that particular evolution we need to make changes and upgradation. Inspite of
innovation and upgradation it could be uncertain to expect good luck into the
survival and expansion of business. Incremental change is a type of change
where change is implemented slowly over a specified period of time (De Wit and
Meyer, 2010). So as to improve the nursing handover we need to implement the
things over a period of time which would give enough time for the individual to
understand and get into the process in a systematic manner. In the same way
there are many different theoretical and models of change. One of the best and
popular cornerstone models for bringing up an organisational change was
developed by Kurt Lewin in 1940 and it is still considered and holds it to be
very true till today. His model is known as Unfreeze- Change- Refreeze which is
referred to be the important three stages of change process. Being a social
scientist he explained beautifully using changing shape of a block of ice. But as
the main aim of this project is to improve the nursing clinical handover which
goes hand in hand with leadership and management of change related to bedside
handover, this project also implies with the ADKAR theory of change.
THE ADKAR CHANGE MODEL
This model is created by Prosci founder Jeff Hiatt, it is
a goal oriented change management model which guides an individual and to make
changes changes in an organization. ADKAR is an acronym that brings out an
achievement for a change to be successfull that is :
A: Awareness; D: Desire; K: Knowledge; A: Ability; R:
Change is a complex process and moreover it is
inevitable. Change is a difficult process in any organization. It is required
to start from a basic level starting from the new thinking, new models and new
frameworks for smooth functioning of the desired change without hampering the
surrounding. This model can be used in a wide range to bring out the change
process in an organization. When this type of model is been used for a change
it allows the leaders and the change management teams to aim on their change
that will make an individual change as to achieve the results of the
organization. ADKAR can give us a clear goal and outcome for change in the
management. It gives a systematic framework so that everyone in the
organization can use and it would be easy to understand and describe the matter.
As the problems included from both the nurses and the patients side which would
likely to be changed as patients have trust on nurses and the management would
be implementing change without compromising patients treatment and care and as
well as the integrity and financial status of the hospital is maintained.
Therefore ADKAR model would be a key for a change in improving nursing
Phase 1: Awareness
In this scenario, firstly the leader should identify the
problems faced by the organization depending upon the nature and depth of the
problem and how badly the organization is been affected should be calculated.
The leader will then find out the root cause of this problem and take into
considerations and try to improve that particular area. From this study the
awareness for the need of change would be explained by taking presentations in
the meeting and the importance of change would be explained in the managerial
level. So that each and every individual will discuss the topics held in the
meeting with their ward colleagues. Based on this the reaction could be vague
but at the same time they would ask for how would it be implemented? How soon
we can put in practice?
Phase 2: Desire
In this there should be a set desired goal. There should
be willingness and approval from the other members of the hospital, its not
only a leaders job to change. Each and every individual of the organization is
equally responsible in their own possible ways. There should be equal
participation and motivation to reach to that particular goal which has to be
achieved in such a period of time. All the participants engagement is very
essential throughout the process. A good team work would boost the energy of
the participant to reach the desired aim. In this patient should be focused
about the adverse effects and risking a patient life as well as to put nurses
profession at risk.
Phase 3: Knowledge
Firstly the persisting knowledge would be assessed so
that we are aware the nurses point of view and how they look into it and how
things are been carried out on a daily basis. Then we would identify which are
the lacking sources and then improve them on that basis. Implementing new
skills and behaviour would not be easily accepted by everyone. So starting from
the improvement and then gradually introducing new skills would make sense to
them and they would put into practice. Adequate training should be provided to
get the best out from them. On duty training should be given in a practical
manner while handing over. In this a leader would lead the group and train the
Phase 4: Ability
In this only theoretical knowledge is not required. The ability
to perform towards change is also necessary. To bridge the gap between the
knowledge and the ability the employees should be trained in such a area by
giving a scenario so that they can make mistakes and questions would arise. By
this they will understand their mistakes and would not repeat this in future.
To realize the change, staffs also need time. When the ability is achieved,
changes take place and we can see the demonstrated new behaviours in practice.
Phase 5: Reinforcement
Human brains have a wiered behaviour and physiologically
it is been programmed to revert the old behaviour. The change which is
implemented should sustain so we need to reinforce the group. To keep on
checking whether the change is sustained or not. If not, where it is on hold
and try to recognize it. Positive feedback is a great way to reward the
employees for making the change and to demonstrate that participants plays a
vital role. If many are reverting back to the same method then check if they
need more training and reinforce them that they have to keep on working on the
acronym for Projects IN Controlled Environments) is a process based method for
effective project management (Hederman et al., 2012). PRINCE2 is widely
recognized and also used in private sectors both in the UK and internationally.
PRINCE2 was published in 1996 and have contributed to some European organizations.
The PRINCE2 framework says that a project should have: organisation and
controlled start (organise and plan before leaping), organised and controlled
middle (keeping projects organised and controlled), organised and controlled
end (project is finished and tidy up the loose ends). PRINCE2 model, which
spans across four stages such as starting up stage, initiation stage,
subsequent delivery stage and first delivery stage. It is recommended to use
PRINCE2 because of the methodology it follows. PRINCE2 is a proven project
management methodology capable of delivering result.
The strengths of the project plan is it is long term use,
realistic and detailed information can be covered for implementing the project.
On the other hand it also implies with the feedback method and training method
as a part of the project. Another strength of the project is that we have a
documented proof and it would be completed on time to time basis. As per the model
if we go through the same procedure all the important information will be
covered without missing any single point. The best strength would be time
allocated to implement this project would be limited to 3 months. Whereas the weakness
would be important documentation would be overheard by other patient and
misinterpretation would lead in other patients mind.
Nonetheless, the project plan is designed for the maximum
efficiency and completion of the project on time. From the leadership potential,
the role of the leader will be integrated with all the process involved in the
project plan, especially in evaluating the performance of the project, interacting
with the staffs, evaluation of the result, and the assessment of short term
goal completions. On the other hand project plan is only a part of wider change
management, which is ultimately managed and lead by the change leader.
This research found that there is a need to change
especially because if there is no such systematic nursing clinical handover, we
would put the life of a patient in risk. It is been found that the clinical
handover is been taken according to the favour of the staff and the practices been carried out since a
long time is been carried out. Based on the findings a new initiation has been
implemented using the ADKAR five phase change model. Similarly, a project
management plan was also implemented using the PRINCE2 methodology. Although the
research has been recommended appropriate actions to achieve the research purpose,
its success mainly depends entirely on the leader handling the change process
and implementing the bedside handover. So it can be concluded that the leader
has a strong role to play to bring about the change in the organization.