IJNHCR

Introduction

On a daily basis, in every healthcare facility, the responsibility for the care of patient is transferred between care providers. This process occurs in active environments that are typical of those in healthcare today. The communication of patients’ information to the next care provider can be known as “report”, “end-of-shift report”, “handoff” or “handover”. This communication is the exchange of information necessary for patient care to continue as planned. Three primary things are transferred during every handover i.e. information, authority and responsibility [1]. The formal part of handover is transferring patient care and responsibility from one nurse to another thus, enabling the nurse to deliver safe and ultimately quality nursing care. Clinical handover was identified as one of the key focus areas. Handover is described as the transfer of professional responsibility and accountability for some or all aspects of care for a patient or group of patients to another person or professional group on a temporary or permanent basis [2].

Handover is an integral part of clinical practice. It is so important that it is a process in which information about patient care is communicated in a consistent manner from one health care provider to another. Adverse patient events as a result of inadequate communication have been identified as a leading cause of death and injury in hospitals in the United States despite evidence-based efforts to reduce their occurrence. Nurses play a vital role in the process of communication and exchange of patient’s information through handover however minimal guidelines are available regarding handover in current nursing practice [3]. Globally, major healthcare institutions are looking at strategies to strengthen the efficacy and efficiency transfer of essential patient care information during nursing inter-shift handover. Communication during patient care, handover is ranked as fifth priority patient safety initiatives [4]. Bedside handover allows organizations to address the National Patient Safety Goals established by the Joint Commission addresses hospitals to encourage patients’ active involvement in their own care as a patient safety strategy (goal 13) and to aim to improve the effectiveness of communication among caregivers [5].

Nursing has had a long relationship with handover. Handover is a historic, institutionalized ritual that has remained part of nursing culture throughout the decades. Its roots lie deep in nursing tradition and nursing handover practice continues without questioning its purpose in contemporary times [6]. Nursing handover typically occurs at change of shift and shifts change two, three, or more times daily, seven days a week. The handover is seen as an important part and vital method of passing pertinent information about patients to nurses on next shift. Mainly there are four types of handovers is recorded, written, verbal (traditional) and bedside but nurses receive little formal training in this critical responsibility [7]. Location of handover varied depending on the needs of each specialty and impacted on what information was transferred. Namely, in a medical/surgical unit, handover was at the bedside [8].

The Joint Commission has acknowledged that communication breakdown is the major contributing factor in nearly 70% of adverse medical events with 75% of adverse events leading to patient death. Miscommunication is also a leading contributor of patient harm identified in more than 80% of medical malpractice lawsuits. In 2012, the Journal of Advanced Nursing reported that more than 43% of malpractice claims were related to inaccurate or incomplete patient handovers and that only 43.9% of accurate patient information actually reached the patient care unit during a patient transfer [9]. Accurate and timely communication of vital information between professional registered nurses is essential to assure patient safety. One of the most important times for nurseto-nurse communication is during the handover when information is exchanged and the responsibility of care for the patient is transferred [10]. It cannot be neglected the fact that handover in patient care is not part of the official education programs in nursing schools. So, nurses do not undergo any regular and particular training at undergraduate level and nurses learn the way of giving handover within the wards culture. Although the handover value for the nursing practice remains still one of the most important rituals of the nursing shift but sometimes it probably may not receive the proper attention from nurses [11].

Handover serve many functions, from social bonding to coaching and teaching, to team building but the most important function of handover is information processing to make sure that essential data are transferred for patient safety. Handover has been identified as a point at which errors are likely to occur. Failure in handover is a major preventable cause of patient harm and is principally due to the human factors of poor communication and systemic error. These can lead to inefficiencies, repetitions, delayed decisions, repeated investigations, incorrect diagnoses, incorrect treatment, avoidable readmissions, increased costs and poor communication with the patient. Verbal handover remains the popular way of communication at shift report this method augmented with a preprepared handover sheet will avoid the loss of vital information that may result in serious patient morbidity or mortality [12]. Despite the well-known negative consequences of inadequate nursing handover, very little research has been done to identify best practices. There is remarkable consistency in the anecdotally suggested strategies but there is a paucity of evidence to support them [13].

Though many researches are being conducted and standard protocol regarding handover are being used in developed countries, sentinel events are still occurring. Therefore, researcher is interested in exploring the practice regarding handover among nurses in developing countries like Nepal where very few studies regarding handover are available. Furthermore, it is important to determine how and in what way nurses carry out patient handover, what are taken into consideration during handover and what kind of problems are encountered during the process. Majority of the studies were carried out in western countries and very few have explored the practice regarding handover among nurses in our part of the World. So, the researcher strongly felt the need for in-depth understanding of the practice regarding handover among nurses to lay the foundation to improve future nursing handover processes and to provide suggestions and guidance to the nurses in the light of the results obtained for a better understanding of functions and implications of handover process for its effectiveness.

Materials And Methods

A descriptive cross-sectional study design was used to find out the practice regarding handover among nurses working in critical care units at selected teaching hospitals, Chitwan, Nepal. This study was conducted at critical care units i.e. Medicine Intensive Care Unit (MICU), Neuro Intensive Care Unit (Neuro-ICU), Surgical Intensive Care Unit (SICU) and Coronary Care Unit (CCU) of Chitwan Medical College Teaching Hospital (CMCTH) and College of Medical Science and Teaching Hospital (CMSTH). College of Medical Sciences and Teaching Hospital with 750 beds is the first teaching hospital in Chitwan district affiliated to Kathmandu University established on 1996. Likewise, Chitwan Medical College Teaching Hospital is 750 bedded hospitals affiliated to Tribhuvan University was established on 2006. Both hospitals are situated at Province number 3 and lies at the height of Bharatpur. Both teaching hospitals are tertiary level hospitals at Chitwan, having various critical care units with sufficient patient’s flow. Therefore, these setting were selected to conduct this study. The population of this study were all the nurses who have acquired one of the professional qualification PCL (Proficiency Certificate Level) nursing, BN (Bachelor in Nursing) and B.Sc. (Bachelor of Science in Nursing) working in critical care units and who provided handover during shift change. Non probability, enumerative sampling technique was used. In this study total sample population were (N=113) nurses but sample available during study was (n=108) therefore sample size (n) was 108 nurses. Those nurses, who were working in adult critical care units of CMCTH and CMSTH and those nurses who were available during data collection period and gave informed consent to participate in the study were included in the study.

Standardized guidelines Situation, Background, Assessment, Recommendation (SBAR) [14] along with the added components, preparatory phase (before handover), early phase of handover and after handover was used to observe practice regarding handover among nurses. Practice observation checklist was further categorized into 3 parts i.e. Part A (preparatory phase before handover), Part B (during handover phase which included SBAR components) and Part C (after handover phase). The components preparatory phase (before handover), early phase of handover and after handover were added in the guideline with the permission from the original author who developed SBAR guidelines. The added component in practice observation checklist was developed by the researcher after review of literature. Experts in School of Nursing, Chitwan Medical College had guided and provided their opinion throughout development of instrument.

The content validity of the research instrument was established by consulting research advisor and a group of professionals from nursing research (thesis) committee, School of Nursing, Chitwan Medical College. Pre-testing was done among 12 nurses of Universal College of Medical Science (UCMS), Bhairahawa, Nepal. On the basis of pretesting practice observation checklist was modified. Practice observation checklist had 66 items with dichotomous responses therefore; reliability was calculated by using Kuder Richardson formula 20 (KR-20). Calculated KR20 value for practice instrument was 0.78, which showed a high degree of internal consistency. Calculated inter-rater reliability of practice instrument was 96.9%, which indicated almost perfect strength of agreement between observers.

Prior to the commencement of the study, approval was taken from the Nursing Research (Thesis) Committee (NRC), School of Nursing, Chitwan Medical College Bharatpur-5. Data was collected after getting ethical clearance from Institutional Review Committee of Chitwan Medical College (CMC-IRC). Researcher collected the data from 23rd June 2017 to 22nd July 2017. Researcher herself collected the data in each shift (morning at 7 a.m., evening at 12 noon and night at 7 p.m.) by structured observation using event sampling method. During period of data collection researcher went to the research setting with oncoming nurse 15 minutes earlier in each shift before next shift starts (morning at 6:45 a.m., for evening shift at 11:45 a.m., and night at 6:45p.m.) and spent 2 hours in each shift as well as participated in normal work during that time. The total data collection duration took about 15-20 minutes for each nurse. Practice regarding handover was observed by taking permission from concerned authority (Hospital Director and Matron).

Researcher took written informed consent from each nurse prior to data collection after explaining the purpose of the study. No respondent was forced or coerced or intimidated in any way to participate in the study. Respondents were given right to reject or discontinue from the study at any time without any penalty. Researcher observed practice regarding handover using practice observation checklist by no concealment and participant observation method. It took approximately 5 minutes for nurses to give handover of each patient which was observed by the researcher during the time of shift change. Vital areas were noted during observation and the checklist was filled up immediately after completion of observation of each handover at nursing station without letting the nurses know about it. Researcher collected data from 6-8 nurses daily altogether in three shifts. Practice observation check list were coded as N1 to N108 of 108 nurses.

After collecting data, at first, the data was reviewed and checked for its completeness, consistency and accuracy after getting back from respondents. The collected data was organized, coded and entered in Epi Data 3.1 version and exported to Statistical Package for Social Science (IBM SPSS) version 20 for descriptive and inferential statistics. Descriptive statistics of quantitative data was presented by frequency, percentage, mean, standard deviation and mean percentage. In addition, Kolmogorov – Smirnov test was

used to check the normality of data distribution of practice, then practice score was further classified into two levels based on Receiver operating characteristics (ROC) curve (Figure 1) and mean score respectively. In the inferential statistics chi-square test, likelihood ratio and yate’s correction were used to find out the association between level of practice with the independent variables of the study.

Figure 1: Receiver Operating Characteristics (ROC) Curve Regarding Practice of Handover among Nurses.

Results

Table 1: Socio-demographic Variables of the Nurses.

Table 2: Profession Related Variables of the Nurses.

Table 3: Health Care Environment Related Variables.

Table 4: Mean Score of Practice Regarding Handover among Nurses.

Figure: Receiver Operating Characteristics (ROC) Curve

Accuracy of discrimination is assessed by the area under the receiver operating characteristics (ROC) curve. Because the sensitivity and specificity can be manipulated by adjusting the decision threshold, there is a need to evaluate the accuracy and discrimination of practice over wide range of cut off points. This is possible with the use of ROC curve. The ROC Curve plots the sensitivity (Y-axis) against 1-specificity (X-axis). The area under the ROC curve (AUC) is a measure of how well a parameter can distinguish between two diagnostic groups. For practice score of nurses regarding handover the area under the curve was 0.643. An area under the ROC curve 643 describes a situation in which the practice score of nurses covers 64.3% area of the curve. When the area under the curve is 64.3% the minimum difference of sensitivity and specificity was at the point where sensitivity was 51% with specificity of 64.9% which gave the cutoff point of score 33.5. As overall compliance was found very low (49.9%) from this cutoff point practice was classified into two categories as fair and poor.

Table 5: Level of Practice Regarding Handover among Nurses.

Table 6: Association between Level of Practice Regarding Handover among Nurses and Socio-demographic Variables of Nurses.

Table 7: Association between Level of Practice Regarding Handover among Nurses and Profession Related Variables of Nurses.

Table 8: Association between Level of Practice Regarding Handover among Nurses and Health Care Environment Related Variables.

Discussion

In health care institutions, work must continue 24 hours a day and 7 days a week. As nurses are the primary caretakers of the patients a team of nurses need to provide patient care in around-the clock basis which requires transfer of patient care responsibilities along with authority, a process known as “handover”. Although handover has been a routine aspect of nursing practice for decades many literatures have shown that the practice and perception regarding handover still needs improvement. The mean age of nurses was 22.49±1.88. Due to high turnover rate of nurses, hospital has to recruit newly graduates with less professional experience hence most of the nurses belong to age group of 20 - 24 with low mean age. Regarding the gender of the nurse, the present study revealed all the nurses (100.0%) were female. This high proportion of female nurses was most probably due to the fact that the enrolment of the nursing students in Nepalese universities and nursing school available only for females, the profession of nursing in Nepal is mostly feminine. Nearly one fourth of the nurses (21.3%) were married. The present study revealed all the nurses (100.0%) were residing outside the nursing quarter and the reason behind is most of the private hospitals in Nepal have no provision of nursing quarter.