issues in clinical bedside handover in nursing practice

 

The issue: clinical bedside handover in nursing practice.

In a simple way, clinical bedside handover can be defined as the transfer of professional accountability and responsibility of some or the entire patient’s (or group of patients’) care from one professional to another on a temporal or permanent basis (Chaboyer, et al., 2012). As an example, if a patient is in a hospital where nurses work on different shifts (morning and night), and it is expected that the patient will have to stay for the two shifts, clinical handover does imply how the nurse on the morning shift will be able to accurately transform the patient’s entire health information to the nurse on the night shift with the aim of making sure that the patient continues to get the required and desired treatment (McMurray et al., 2009).

Both locally and internationally, clinical handover has been identified as a critical and high-risk step when it comes to assessing a patient’s hospital journey (Bradley & Mott, 2010). It is one of the most perilous processes in medicine, and in the event that it is not properly handled, it could lead to more errors and potential negative impact on the health of a patient (such as giving a patient the wrong medication and treatment).

In past literature and surveys, a number of factors have been identified as the reasons for variations in clinical handover, and such include differences in views, beliefs, cultures, and poor communication, which lead to professional differences in nursing standards when it comes to clinical behavior (Iloka, 2018). From the patient’s side, there are also factors that hinder qualitative clinical handover, and one such is the increased complexity of care as well as the profile of the diseases that could lead to more treatment being required and a high burden of illness (Australian Department of Health, 2015). Regardless of the factor, clinical handover is critical, and nurses must ensure strict adherence to standards in order to provide the best quality health care to patients while avoiding complicating their health issue(s).

Why is clinical bedside handover an issue?

In the nursing profession, bedside handover is a serious issue because poor handover does yield numerous risks for the patent (Iloka, 2018). The risk associated with poor beside handover (whether it is coming as part of handover in shift, inter-departmental clinical handover, or just due to flow of information and communication) is that the health conditions of the affected patients can deteriorate, making it a big issue in the clinical setting (Chaboyer et al., 2008). Generally, the risks are similar based on the discussion below.

First, poor clinical bedside handover does bring about delayed and inappropriate treatment for patients, and this can further delay clinical referrals. The outcome of which would be increased threat to the patient’s life in an acute setting (Iloka, 2018). As a result of poor bedside handover, a patient that is supposed to get surgery in 1 hour might end up being attended to in a couple of hours, further putting the patient’s life at high risk.

Secondly, poor clinical bedside handover can yield incomplete or inaccurate information, and if the patient notices the difference in the communication between the nurses taking care of their health, they will lose confidence and trust in both the nursing staff and the hospital (Iloka, 2018).

Thirdly, this issue can result in inefficient use of time and resources, ultimately leading to a break down in continuity of care. As an example, if a machine had been set for surgery within the next 1 hour and the machine was forced to function for more than 5 hours due to poor bedside handover, there could be a reduction in the efficiency of such machines and this would ultimately lead to high chances of the machine breaking down in the process (Iloka, 2018).

Finally, poor clinical bedside handover does have the potential to increase hospital bills for the patient because the patient might be eventually treated more than required or get treatment for an illness they don’t suffer from (Chaboyer et al., 2012). Thus, it is clear from the above evidence that the risks associated with poor clinical bedside handover should be taken seriously in order to ensure that the overall health care of patients is not being put in danger by poor professionalism from the nurses (McMurray et al., 2009).

Personal reflection from experience in nursing practice: the need for standardization

I had a personal experience of clinical bedside handover as a patient. I was feeling feverish and was admitted to a hospital close to my university. Unfortunately, I arrived just a few minutes before handover and as the nurse was just getting to understand my health issue, she horridly handed me over to another nurse (who, instead of gaining further insight about my health issue, as I was still expecting to be asked more questions, strongly believing that I had not communicated all the issues to the previous nurse), proceeded straight into treatment.

As a medical student, I noticed in the course of the treatment that some of the medications I was being administered were not meant for what I was feeling. I was only able to spot this difference because I was in the medical line, and as such, it would be generally difficult for non-medically inclined patients to be aware. It was only after demanding a proper recheck that the nurse re-initiated the study of my health – leading to inefficient time and resource usage. If I hadn't been medically inclined, the nurse would have administered the incorrect medication.

Clinical bedside handover research findings

From 2007 to 2008, the Australian National Nursing Research Unit studied over 500 cases of clinical bedside handover with over 30 nurse interviews in 6 wards of two hospitals in Queensland and Western Australia (National Nursing Research Unit, 2012).Their findings reveal numerous instances of poor clinical bedside handover, and a change in the management process regarding handover resulted in the successful implementation of various clinical settings.This is in line with the earlier discovery that quality clinical bedside handover comes with an enhanced level of information accuracy, and it helps the nurses function effectively in practice with their patients (Clemens, 2008). On the same note, the study discovered that bedside handover doesn’t increase the time required for handover because about 1.5 minutes is spent in the handover process, underscoring the need for nurses to employ the highest level of meticulousness during the handover process. The oncoming nurses are more active participants, and in the event that they do not receive information passively, it could lead to a higher degree of threat to the patient’s health, and it also calls for the need for privacy of patient to be effectively managed.

Similar findings were also discovered in the UAE setting, where it was found that bedside handover was more effective than the normal handover, but the complication of cases could yield a higher degree of complexity. Similarly, there are recorded cases where the patient does sleep during the handover process and is not able to monitor how effective and efficient the process is (Chaboyer et al., 2012). Additionally, there were cases where handovers initiated at the bedside were completed away from the bedside, which hindered the patient’s full participation during the handover process.

Based on the above findings, it is clear that there is an obvious need for proper clinical bedside handover practice to be implemented in hospitals in order to ensure that nurses pass accurate information about the patient’s health and create an enhanced environment for quality healthcare practice. Based on these limitations, the recommended practice standard is as discussed below.

Recommended standards for enhanced clinical bedside handover in nursing practice.

The aim of this guideline is to provide a working standard setting and framework for clinical handover in the nursing profession. The recommendation is based on five stages: preparation, introduction, information exchange, patient involvement, and safety scan, and they are as discussed below.

Preparation

There are four aspects to this stage. Staff and patient allocation: each patient should be allocated a staff member and the details of this allocation should be published where the staff can easily reference it. Updating the handover sheet—there should be a computer generated handover sheet that contains the information of all the patients in the ward. As such, it will allow the nurses to understand the health conditions of the patients in the ward that they did not receive handover on (See Appendix 1). Informing the patient—the patient should be informed towards the handover time that the handover process will begin shortly. Family and other visitors—they should only be allowed to stay at the patient’s bedside during the handover with the patient’s permission (Chaboyer et al., 2008).

Introduction

At this stage, the team leader of the outgoing team should lead the handover, with the remaining outgoing team members made available to answer call bells and provide other necessary care. Considering that the outgoing team leader (or nurse) has already built rapport with the patient and family, it is vital for them to introduce the incoming team members to them. At this point, it is important to ensure that a personable approach is maintained throughout. In the event that the patients are uncomfortable (such as patients that have sensitive health issues), the handover can be done outside the bedside (Chaboyer et al., 2008).

Information exchange

Generally, the information handed over at the bedside is not different from what would be exchanged in the event of other forms of handover (Chaboyer et al., 2008). However, it is recommended that the staff (nurses) should be cognizant of their language and limit the extent to which they use jargon (See Appendix 2). The incoming nurses can also get more information and observations when they actually look and see for themselves (See Appendix 3).

Patient involvement

Healthcare is a patient-centered approach, and as such, patients need to be involved in the process. During clinical handover, patients should be offered the opportunity to seek clarification, ask questions, and confirm information (Chaboyer et al., 2008). In this case, the outgoing nurse who initiates the handover plays a special role by inviting the patient to ask questions or make comments during the handover.There are a group of patients that might not participate in the process, and they are those who are asleep, comatose, confused, in isolation, or having difficulties with the language being used by the nurses, among other conditions that preclude participation.

Safety scan

In the course of the handover, the incoming nurse should perform a scan of the patient’s environment to ensure that there are no conditions that put the overall success of the healthcare system and efforts in jeopardy. This includes a safety scan of the environment and equipment to ensure they meet all standards; review of the patient in terms of treatment received thus far (such as dressings etc.); and bedside chart review in order to identify additional safety concerns (such as unsigned medications and changes in vital signs) (Chaboyer et al., 2008) (See Appendix 4).

Evaluation of standards

The recommended standard is in line with "The Standard Operating Protocol for Implementing Bedside Handover in Nursing" as prepared by the Australian Commission on Safety and Quality in Healthcare (Chaboyer et al., 2008). Thus, it is an international standard that will essentially lead to an enhanced handover process not just in Malaysia but in global nursing practice.

Dateline and control for implementation.

It is recommended that this standard should be employed immediately across hospitals in Malaysia that are not presently employing it. A supervisory team should also be setup in hospitals to monitor the extent to which these standards are being implemented and guide nursing toward full-and effortless implementation.

Conclusion

In conclusion, nurses need to understand that the overall health of their patients depends a lot on their clinical bedside handover. Thus, they are mandated under oath of care to ensure that patients' health is not put in danger as a result of their poor professionalism. In essence, nurses must maintain the highest level of care and professionalism when handing over patients in the clinical setting.

References

Australian Department of Health. (2015, 11 11). Communication (Clinical Handover) in Acute and Children’s Hospital Services. Retrieved from Australian Department of Health: http://health.gov.ie/wp-content/uploads/2015/12/NCG-No-11-Clinical-Handover-Acute-and-Childrens-Hospital-Services-Full-Report.pdf

Bradley, S., & Mott, S. (2010). Handover: Faster and safer? Retrieved from AUSTRALIAN JOURNAL OF ADVANCED NURSING: http://www.ajan.com.au/vol30/issue1/bradley.pdf

Chaboyer, W., McMurray, A., & Wallis, M. (2008). Bedside Bedside Handover: Standard Handover; Standard Operating Protocols. Retrieved from Australian Commission on Safety and Quality in Health Care: https://www.health.qld.gov.au/psq/handover/docs/ch_presentation1.pdf

Chaboyer, W., McMurray, A., Johnson, J., Hardy, L., Wallis, M., & Chu, S. (2012). Bedside Handover; One Quality Improvement Strategy to “Transform Care at the Bedside” . Retrieved from Griffith University: http://www98.griffith.edu.au/dspace/bitstream/handle/10072/29476/59352_1.pdf

Clemens, T. (2008). Bedside handover – implementing and evaluating change . Retrieved from Royal Children’s Hospital: http://www.awch.org.au/pdfs/conferences/2008/10_CLEMENS_Teresa_2.pdf

Iloka, B., C. (2018). Influence of clinical bedside handover on patient's recovery and health. Retrieved from: http://ilokabenneth.blogspot.com/2018/04/influence-of-clinical-bedside-handover.html

McMurray, A., Chaboyer, W., & Wallis, M. (2009). Implementing Bedside Handover: Strategies for Change Management. Retrieved from Journal of Clinical Nursing: http://www98.griffith.edu.au/dspace/bitstream/handle/10072/34146/64540_1.pdf?sequence=1

National Nursing Research Unit. (2012, 11 12). What are the benefits and challenges of ‘bedside’ nursing handovers? . Retrieved from King's College London: https://www.kcl.ac.uk/nursing/research/nnru/policy/By-Issue-Number/Policy--Issue-36.pdf