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The first concept I learned in SCOHS about taking a leadership role was collaborating with a supervisor about a problem. This was introduced to me through our leadership class, NUR416. For example, I'm the new RN on the floor and I find out important information about my patient that I didn't get in report. Instead of keeping it to myself and brushing this off, I would go to my supervisor with a goal to solve this problem together. Keeping an open mind, I would follow these steps to discuss this hand-off communication problem with my supervisor:

●"Find an appropriate time to discuss the problem, scheduling an appointment if needed

● State the problem clearly and explain why it is interfering with work

● Listen to the supervisor’s response and provide more information if needed

● If I agree on a solution, offer to do my part to solve it. If I cannot--discover an agreeable solution, schedule a follow-up meeting, or decide to gather more information

● Schedule a follow-up appointment" (Sullivan, 2013).

It is important to maintain an honest, open, and collaborative relationship with our supervisors because in the end, they will be the ones managing our workspace. Keeping clear communication will foster improvement and growth in everyone's interpersonal skills.

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The second concept SCOHS taught me is to be the kind of nurse I'd want to have if I was a patient. Specifically to this issue, I would be the kind of nurse that leads my co-workers by providing a good example in providing clear, thorough. communication. Again, from our leadership class, I've learned that "leaders who engage in frank, open, two-way communication and whose nonverbal communication reinforces the verbal communication are seen as informative" (Sullivan, 2013). By diligently incorporating this in my routine as I start my practice, I hope to inspire other nurses and health care professionals to advocate for their patients and provide hand-off effectively.

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This last way of promoting nurses' participation in improving hand-off communication is more in the pro-active realm. I think it would be beneficial for nursing students and new grads to be educated on how to effectively communicate report from the start of their education. By doing this, they will make it a habit to include safe, standard hand-off in their routines as they start to practice in the field.

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A nurse manager's attitude can really set the tone of his or her staff. For example, if he or she perceives any mistake that occurs an opportunity to improve a system rather than to punish an individual, employees will be more willing to admit they made mistakes. From this, hand-off communication can be addressed and the entire staff can work as a team to make their unit stronger (Sullivan, 2013).

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The first way nurses can be encouraged to maintain their participation in providing safe, effective hand-off is having the manager or the charge nurse remind of their impact on families' lives. "By understanding the meaning of the course of illness to the patient and the family, the nurse will manage risk better because that understanding can enable the nurse to individualize patient care. This individualized attention produces respect and, in turn, reduces risk" (Sullivan, 2013). This is one of the ways nurses act as advocates for their patients.

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                        Barriers in Participation

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                        Barriers in Participation

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Possible barriers and causes of limited nurse participation in resolving the issue:

An obstacle that nurses would face in practicing effective hand-off communication is culture, as mentioned in the Roles and Participation section of this project. Sullivan adds that "cultural attitudes, beliefs, and behaviors affect communication".
Another cause of limited participation would be a nurse's listening skills (Sullivan, 2013). He or she could lack self-confidence, and their mind could be racing--instead listening to the information conveyed--because they are nervous. The recipient nurse could also be approaching the end of his or her shift, receiving a transfer patient on the unit. With such little energy left, his or her attention might not be fully focused on all the details given in report.
On the other end of the communication spectrum, other than listening, nurses can have barriers in speaking that interfere with how they give hand-off. "Most speakers overestimate how clearly and effectively they communicate. Speakers assume that the receiver has the same knowledge that the speaker possesses, and the better you know the receiver of a hand-off, the more you may overestimate the quality of what you have communicated and how much the receiver already knows" (Reisenberg, 2012). In order to get over this barrier, nurses will have to give the same information to everybody as if he or she didn't know them. Although it is acceptable to have a rapport and relationship with fellow co-workers, when communicating about patient information, stay focused on the task in order to keep their safety a priority.
The last barrier to a strong hand-off is human memory. "Memory is affected by personal biases, current mood, how tired or rested you are. The receiver simply accepts as fact what the sender said, without critically evaluating the evidence" (Reisenberg, 2012). Our memories will always be flawed, which reinforces the importance of using a standardized communication tool or template to record information throughout the day.

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The importance of the nurse's involvement- how the nurse would be able to help and whether or not that involvement will help improve the issue:

As previously mentioned in the Literature section of this project, the lack of structure posed as a negative influence on hand-off efficiency and efficacy. A major way that nurses can involve themselves in improving the issue of inadequate hand-off communication is by standardizing their information delivery. The Institute for Healthcare Improvement states that "teams can promote safe and efficient hand-overs by having an effective, standardized process. Having a plan for clear communication helps teams deliver appropriate care in any scenario" (Institute for Healthcare Improvement, 2019).
Two standardized communication tools recommended by the Joint Commission include ISBAR and I-PASS (Joint Commission, 2017). ISBAR stands for: Introduction, Situation, Background, Assessment, and Recommendation. I-PASS stands for: Illness severity, Patient Summary, Action List, Situation awareness, and Synthesis by the receiver.
On top of incorporating the use of standardized communication tools to improve hand-off efficacy, nurses can maintain the Joint Commission's 2008 Hospital Patient Safety Goals:

1. "allow for the opportunity of questioning between the giver and receiver of patient information

2. provide up-to-date information regarding the patient's care, treatment, and services, condition, and any recent or anticipated changes

3. verify the received information, including repeat-back

4. give the opportunity for the hand-off receiver to review relevant patient history, including previous care, treatment, and services.

5. limit interruptions, minimizing the possibility that information gets missed or forgotten" (Friesen, 2008b)

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What the nurse is or is not doing related to the issue, and whether or not those actions are improving it:

Related to hand-off communication, some nurses are improving the issue while others are worsening it. Many factors play into how people communicate and how receptive others are to that information. One aspect in particular, culture, can act as a downfall when it comes to nurses' interpretation of others' communication attempts. "Body movement, gestures, and tone are culturally defined. A great deal of misunderstanding results from a lack of understanding of each other's cultural expectations" (Sullivan, 2013). There are nurses out there who incorporate cultural competence in their practice, and these individuals continue to improve hand-off communication. However, not everyone is aware nor open-minded to other cultures' communication styles, which worsens the issue. While it is an unreasonable goal to be aware of every single culture's communication style, it would positively benefit a nurse's practice by becoming familiar with the cultures commonly seen at his or her workplace.

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                                  A n a l y s i s

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                                  A n a l y s i s

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Chelsea Delacruz

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* Hand-off Communication: an Issue in the Clinical Setting *

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* Hand-off Communication: an Issue in the Clinical Setting *

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                                                         References

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                                                         References

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Friesen, M. A. (2008, April). Handoffs: Implications for Nurses. Retrieved from https://www.ncbi.nlm.nih.gov/books
/NBK2649/
Friesen, M. A. (2008, April). Table 1, [Joint Commission 2008 Hospital Patient Safety Goals Implementation
Expectations for Handoffs]. - Patient Safety and Quality - NCBI Bookshelf. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK2649/table/ch34.t1/?report=objectonly
Institute for Healthcare Improvement. (2019). Planning for Effective Communication. Retrieved from http://app.ihi.org
/lmsspa/#/6cb1c614-884b-43ef-9abd-d90849f183d4/3e37eb4a-4928-4d8b-976e-3a2a1a5f2c08/lessonDetail
/c68e7f4d-6da9-4832-81dd-4c35ca4cfc0c/page/4
The Joint Commission. (2017). Sentinel Event Alert: Inadequate hand-off communication. [PDF file]. Retrieved from
https://www.jointcommission.org/assets/1/18/SEA_58_Hand_off_Comms_9_6_17_FINAL_(1).pdf
King, B. J., Gilmore-Bykrovski, A. L., Roiland, R. A., Polnaszek, B. E., Bowers, B. J., & Kind, A. J. (2013). The
Consequences of Poor Communication during Transitions from Hospital to Skilled Nursing Facility: A Qualitative
Study. The American Geriatrics Society, 1095-1102. Retrieved from http://www.leadingagewi.org/files
/caretran613.pdf
Riesenberg, L. A. (2012). Shift-to-Shift Handoff Research: Where Do We Go From Here? Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312531/#i1949-8357-4-1-4-Joint2
Sullivan, E. J. (2013). Effective leadership and Management in nursing (8th ed.). Upper Saddle River, N J: Pearson,
Prentice Hall.

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                                R e f l e c t i o n

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                                R e f l e c t i o n

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Concepts learned during my education at Sentara College of Health Sciences (SCOHS) and how they prepared me to take a leadership role once I transition to professional practice:

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                        R e c o m m e n d a t i o n s

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                        R e c o m m e n d a t i o n s

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to promote and strengthen the nurse's participation to improve the issue:

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                                                                                L  i t e r a t u r e

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                                                                                L  i t e r a t u r e

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Hand-offs happen very frequently in health care, especially in hospitals. "It's estimated that a typical teaching hospital may experience more than 4,000 hand-offs every day" (The Joint Commission, 2017). With hand-off frequency occurring at that magnitude, the same amount of miscommunication opportunities arise as well.
"An estimated 80% of serious adverse events can be linked to miscommunication between caregivers when patients are transferred or handed over" (Institute for Healthcare Improvement, 2019). Some of these adverse events include: wrong-site surgery, delay in treatment, and medication errors. These adverse events happen because of the loss of information between hand-off participants. Every year, "the Agency for Health Care Research and Quality hosts a survey of hospital patient safety culture. In 2011, 1032 hospitals and over 470,000 hospital staff responded. 50% of the participants endorsed the statement that 'important patient care information is often lost during shift changes'" (Reisenberg, 2012).
As previously stated, hand-off occurs between hospitals and care facilities when a patient is discharged. The American Geriatrics Society mentions that "inadequate hospital discharge information to skilled nursing facilities causes problems". These involve medication orders, insufficient information on patients' psychosocial or functional history, and inaccurate facts regarding current health status. The lack of this communication clarity results in "repeated telephone clarifications, delay in providing care, and frustrated family and staff members". All of these factors puts patients at risk for re-hospitalization.  (King, et. al., 2013).
One cause of this ineffective communication is the lack of structure and focus during the process, which instead gets substituted for casual conversations. The Joint Commission found a study in which "69 percent of clinical learning environments did not have a standardized hand-off process, and only 20 percent had some standardization" (Joint Commission, 2017). They also determined the issue of hand-offs so prominent that a list of national patient safety goals have been effective since January, 2006 (Friesen, 2008A). That list of goals will be addressed in the Analysis-Involvement section of this project.

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                                                                                  I s s u e 

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                                                                                  I s s u e 

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The area of concern in this project is hand-off communication between nurses and other health care providers in the clinical setting. This has become an issue because of the way people convey information from one caregiver to the next. For example, hand-off should be done at the patient's bedside, but that does not always happen. Some RNs take this "opportunity" to provide subjective information not related to the patient's care. This could make it difficult for the nurse on the receiving end to maintain his or her focus on the crucial facts needed to provide care during his or her shift. It is important to be aware of and to correct gaps in communication because hand-off occurs at multiple times during the day. A nurse can deliver hand-off between shift changes, during transfers, and when a patient gets discharged to a care facility, to name a few. Without objective, concise, and thorough communication, the continuity of patients' care becomes compromised, interfering with his or her health and safety.