Nepean Hospital provided patients in a trial ward with a template containing prompts, so they could deliver a handover of their healthcare journey once a day to nursing staff.
To ensure that within six months, 80% of all patients (with the assistance and involvement of their families and carers) admitted to the trial ward at Nepean Hospital deliver patient handover once a day during their admission.
- Increases engagement with patients, families and carers.
- Reduces complaints related to communication.
- Improves the safety and satisfaction of patients.
- Enhances the patient’s understanding about their treatment.
- Prepares patients, families and carers for the expected date of departure.
- Increases satisfaction and collaboration among nursing, medical and allied health teams.
Prior to the project, patients, families and carers in the trial unit at Nepean Hospital were provided with limited opportunities to demonstrate an understanding of their healthcare journey, ask questions or provide feedback to nursing staff during their stay in hospital. There were also a number of complaints where communication was the core of the problem.
A number of strategies were implemented in recent years to address this problem, including moving patient handover to the bedside, as well as implementing different clinician-led rounding models. These were successful in changing the handover location and format, but did not increase engagement with and participation of patients, families and carers.
An audit conducted in the trial unit over a three-year period from October 2013 to September 2016 showed an increasing trend in falls incidents and complaints, as well as an increasing rate of clinical incidents with patients who had non-age related cognitive impairments (such as those secondary to acute illness or substance abuse). It also showed that other units who managed patients with neurological issues had a falls rate higher than the hospital average.
During investigation of these falls incidents, it was noted that patients with cognitive impairments were given mobility instructions by staff before they fell. However, these instructions were not followed by the patient. It was unclear why they did not call staff to help them before they started moving as requested. When asked if they understood the instructions by staff after the incident, they said they did but clearly did not. This may have been a result of the cognitive impairment impacting their ability to retain information, language used by staff that was not easily understood, or a combination of both.
It was determined that a daily handover would allow patients (with the assistance and involvement of their family or carers) to tell staff what help and equipment they need before moving. It would also allow staff to confirm that patients understood mobility instructions, to increase compliance and reduce falls. The handover would also prompt staff to spend more time communicating with patients, families and carers if the patient didn’t understand any element of their care plan.
A template was developed to help patients deliver their handover and share information on their healthcare journey with nursing staff while in hospital.
The handover is undertaken at 2pm each day and participation is voluntary. Families and carers are encouraged to be involved, with the patient’s permission.
The handover form collects the following information:
- the reason they are in hospital
- how they are feeling that day
- if they have been reviewed by a medical team and what they said
- if they have been reviewed by an allied health team and what they said
- what they need to do before they walk
- what they need help with each day
- when they hope to go home
- whether there is anything they are worried about
- whether there is anything that staff need to know
- whether there is anything else they feel is important to share.
At the conclusion of this handover, nursing staff complete a ‘safety huddle’ at the nurses station where they handover any sensitive information, safety concerns or feedback that may impact the ward, before the next shift begins.
Nursing staff must ask medical or allied health teams to go back and talk to the patient again if the patient is unable to describe why they are in hospital, is unsure of what clinicians have said to them or if they have any questions. Any other concerns are referred to the appropriate staff member.
Implementation - The initiative is ready for implementation or is currently being implemented, piloted or tested.
October 2016 – March 2017
Nepean Hospital, NBMLHD
Clinical Excellence Commission Clinical Leadership Program
A pre-implementation survey was conducted with staff and patients in September 2016. Results showed:
- 8% of staff always included patients in handover
- 8% often included patients in handover
- 50% sometimes included patients in handover
- 34% never included patients in handover
- 78% of patients stated they were not included in handover.
A post-implementation audit conducted in January 2017 showed that patient handover was occurring at each bedside. Comments from patients and staff included the following.
- “I felt that the handover process was well done. It was great to feel valued and included.”
- “Doing the handover in front of the patient is a good idea, it makes the patient feel more involved with their treatment and encourages confidence with the nursing staff.”
- “I feel good about expressing myself, and more confident.”
- “Felt involved.”
- “This is a great idea.”
- “Makes you feel welcomed.”
- “Very valuable process. We need to be able to see the level of understanding a patient has about their condition and plan. Gives patients an opportunity to voice their concerns as well as their families’ concerns. Avoids unnecessary handover (as it is already on the handover sheet).”
- “Communication between nursing staff, patients and their relatives seem easier and happening more frequently.”
- “I enjoy the patients’ handover.”
- “Nursing staff can immediately address issues and concerns.”
- “[It’s] one of the best to reach the patient’s issues and concerns…”
Survey results for the question “staff include me in their handover from shift to shift” were as follows:
- pre-implementation—6% always, 0% often, 16% sometimes, 78% never
- post-implementation—96% always, 2% often, 0% sometimes, 2% never.
Survey results for the question “staff value my opinion and seek information from me” were as follows:
- pre-implementation—6% always, 69% often, 6% sometimes, 19% never
- post-implementation—73% always, 9% often, 18% sometimes, 0% never.
The number of falls and complaints in the unit was monitored, with results indicating a downward trend in both following implementation of the project.
Planning has commenced for the implementation of the project across all units in Nepean Hospital.
Future solutions will include pre-education for nursing staff on patient engagement and what patients are looking for in their healthcare journey.
The greatest challenge was changing staff perceptions about what patients actually want. Staff were initially concerned about privacy, patients feeling embarrassed, staff overwhelming patients and clinical handover being neglected. However, they acknowledged that patients and their families appeared to like the idea and process, and did not receive any negative feedback. With continued positive feedback from patients, staff gradually changed their perception and became advocates for the new handover process.
Nurse Manager, Nursing and Midwifery Directorate
Nepean Blue Mountains Local Health District
Phone: 0439 140 187