Adapting SBAR Handoff to Simplify the Patient's Story: A ...
Adapting SBAR Handoff to Simplify the Patient's Story: A Process Improvement ProjectMarie WendtMidMichigan HealthAuthor Affiliation: Marie Wendt is the Nurse Manager Surgical Intensive Care Unit at MidMichigan Health, Midland, Michigan, USACorrespondence: Marie M. Wendt, BSN, RN, MidMichigan Health, 4000 Wellness Drive, Midland, MI, 48670. (E-mail: marie.wendt@) Phone: 989-839-1579Conflict of interest statement: The author declares there are conflicts of interest.AbstractStandardized handoff processes in healthcare have demonstrated increases in registered nurse (RN) collaboration and patient safety. Despite this, uncoordinated handoffs continue to occur in critical care settings, jeopardizing patient safety and negatively impacting nurse satisfaction. By employing Lewin’s Change Theory of unfreezing, moving, and refreezing, a performance improvement project for developing and initiating an evidence based standardized Situation, Background, Assessment, Recommendation (SBAR) handoff tool was piloted for a period of four weeks. The project lead demonstrated Relationship Based Care and Transformational Leadership styles of behavior during the Plan-Do-Study-Act cycle method for process improvement. The introduction of a modified SBAR paper tool demonstrated that when utilized to its full capacity there was an improvement in nurse satisfaction in knowing the patients story.Key words: Handoff(s), Shift Report, Nurses Report, Handoff Communication, Standardized Report. Accurate shift to shift handoff is essential for safe patient care. For critical care registered nurses (RNs), it is vital to understand the patient’s story to safely care for them. Patient handoff is significant in critical care units where nurses are accountable for two seriously ill patients simultaneously.1 When nurses work 12 hour shifts, there can be a lack of continuity of care from day to day. It is important to have a consistent method to relay the original information from the date of admission throughout the patient’s length of stay. Using evidence based practice (EBP), a Situation, Background, Assessment Recommendation (SBAR) report tool was created and implemented at shift-to-shift handoff in a neuro trauma intensive care unit (NTICU), in an effort to improve the RNs knowledge of the patient’s overall story prior to beginning patient care.Support for ImprovementThe Joint Commission (JC) defines handoff as “the transfer and acceptance of patient care responsibility achieved through effective communication.”2 According the JC, miscommunications during collaboration between care givers accounts for 66% of errors in healthcare.3 The Agency for Healthcare Research & Quality (AHRQ) published that 49% of survey respondents in one study, stated that information is omitted during shift to shift changeover.4 In an effort to impact this safety concern, the JC included nurse collaboration in its 2007 National Patient Safety Goals.5 The National Patient Safety Goal (NPSG) included a formalized process for handoff where nurses to have time to ask questions during the handoff. Despite this NPSG, governing agencies have not recommended one consistent method of handoff for ensuring patient safety. Adding to this challenge, there is minimal evidence to support any one single method.6 Nonetheless, there are strong recommendations in healthcare to formalize the handoff process.7 Standardized checklists is one strategy. By incorporating standardized checklists, one study demonstrated a decrease in complication rates in 6 hospitals from 27% to 17%.8 Studies such as this demonstrate the need for critical care nurses to adopt a method which incorporates various evidenced based best practice reasoning into their own handoff procedure. There are many barriers to performing an appropriate, safe, and meaningful handoff at change of shift. These barriers include but are not all inclusive; lack of standardization, lack of policy related to handoff, staff resistance, lack of research data to support best practices, time constraints, an increase in the complexity of care, inadequate training, and department cultural norms.9 A further look at the barriers specific to NTICU’s handoff process will be looked at later in this article. It is important to understand and address any barriers when attempting to improve processes. Plan Stage (Phase)The EBP standardized SBAR method for handoff has been demonstrated to decrease errors with nursing practice. In 2010, Mission Hospital in Mission Viejo California, reported 750 near misses being thwarted by the use of instituting standardized tools such as SBAR for handoff communication in a six month time period.10 Stevens goes on to report that pharmacy related errors decreased from 18% to 2% in 2010.11 Other research demonstrates the amount of patient information omissions decreasing from a mean of 4.96% to 2.29% per handoff, with a result of home medication issue error rates decreasing from 38% to 9%.12 Additionally, this study exhibited a decrease lack of RN knowledge related to abnormal laboratory findings from 90% to 48%.13 Evidence indicates being thoroughly organized with information sharing at handoff is critical.14 The SBAR approach provides such methodology. This method has also demonstrated to be an effective means for healthcare providers in acute and non-acute care settings.15 The commonly used SBAR practice is known for assisting to decrease inaccurate and unstructured handoffs in healthcare.16 Therefore, an SBAR approach was adopted for the project. The NTICU Shift to Shift RN Handoff Performance Improvement Project set out to implement a safe consistent method for relaying pertinent information between RNs working opposite shifts. The NTICU was chosen for the project for its long lengths of stays related to multiple traumatic injuries. These characteristics add to the complexity of relaying each patient’s and family’s story. The NTICU RNs stated that they wanted to improve patient safety and collaboration, voicing concerns of not having a full understanding of the patient’s overall story.Well thought out designing during the planning stage of the performance improvement project is the foundation of its success. In preparation for the Shift to Shift Handoff Project, a project template was designed with timelines, goals, and objectives. The project template was utilized as a guide for keeping the project moving forward. The Plan Do Study Act (PDSA) method was utilized for project completion. According to the AHRQ, the PDSA cycle is an uncomplicated method to fast track process improvement.17 In an effort to obtain peak buy in from the staff RNs, the NTICU nurse manager was queried for those staff that were strong advocates for process improvement or passionate about improving the shift to shift handoff process. The project lead also emailed all NTICU RNs to elicit enthusiasm and volunteers. Both of these methods resulted in 2 team members formally joining the project. One from each shift. The project team performed a root cause analysis (RCA) to determine the department’s barriers to performing a consistent comprehensive shift to shift RN handoff. The results concluded that the neuro trauma intensive care unit’s barriers were similar to the barriers published in EBP. These included recent changes in patient acuity, concerns with electronic medical record (EMR), lack of tool consistency, time constraints, nurse experience or training and cultural pressures between staff.18 Specific conclusions ascertained from NTICU’s RCA were concerns with process, tools, communication, time constraints, technology, environment, education, and staff culture. Process included inconsistent practices from the various RNs having no policy to direct them. Tools involved not having a single consistent method that is evidence based. Communication discovered omissions and inaccuracies in information being shared. Time constraints pointed towards staff concerns of bedside handoff taking too long. Technology is not user friendly, offering little useful information and is extremely slow to obtain. The environment on the unit is too noisy with numerous interruptions. There is a lack of education on handoff during orientation and there is no educator to support the process. Lastly, the staff culture is plagued with various attitudes regarding handoff and their processes are unorganized. (See figure 1)According to the Joint Commission Center for Transforming Healthcare, providing a structured process such as the Hand-off Communications Project can improve the RN receiver’s perception of satisfaction by 52.9% 19. The custom for NTICU is to use blank sheets of paper in an unstructured manner. A baseline survey was electronically emailed to all 18 RNs to gain an understanding of their impression and satisfaction of the current unstructured method for their handoff process. Nine of the 18 RNs responded to the five question survey. (See figure 2) 66% of the responses indicated that they were slightly dissatisfied with knowing the patients story after handoff. 77% of the respondents answered slightly satisfied with having sufficient enough information to care for their patients after handoff. To understand the pre project handoff process the project lead observed a total of ten different shift to shift RN handoffs, five on each shift. The current handoff process, demonstrated by seasoned and newer critical care nurses within the department, substantiated being a challenge with relaying information appropriately. The observations demonstrated the various aspects of the shift to shift RN handoff in the NTICU. First, the RNs meet one on one and provide verbal report at a crowded nurse’s station. Second, nurses utilizes a paper tool that they are most comfortable with for the handoff process. Many of these tools were blank sheets of paper. While others were quite detailed. Third, the electronic record is utilized very little for shift to shift handoff. The nurses find the current software to be cumbersome as well as time consuming. After the nurses receive the verbal handoff from the previous shift, they spend considerable amount of time in the EMR researching the patient and what has occurred during their critical care hospital stay. This practice is not a nurse satisfier. The nurses frequently identified omissions from the handoff process later during their shift. In one research study, nurses on surgical units had an increase of 33% of patient information to keep track of more than medical units during shift to shift handoff.20 Among trauma patient populations, there are usually lengthy informative patient story that is difficult to convey shift to shift and day to day for each patient. This information must be accurately conveyed for a period of weeks or longer. This demonstrates the need for a more structured handoff process. The project team reviewed evidence based literature, tools, and anecdotal reports from previous experience and various organizations to develop a new handoff process. Criteria was developed by the team for the desired process. The project team designed a formalized tool for handoff on the eight bed NTICU. This resulted in an abridged version SBAR format in paper form. (See figure 3) By removing the Assessment sections from the piloted SBAR tool, each individual nurse reported a head to toe assessment separately from the piloted tool. This allowed the RN staff flexibility to customize their head to toe assessment.After numerous formal and informal project team meetings, a card stock paper tool was developed for the Situation and Background and Recommendation sections of the standard SBAR report process. The RN staff determined what was to be included in the tool which was kept in the patient’s binder for the duration of their stay. These things included: diagnosis (Pt Story), procedures, abnormal/critical labs values on admission, and pertinent history. These things were written in pen on admission. Also included were: family dynamics/concerns, physician/patient & family plan, blood products, and current lines/tubes/devices which were updated each shift in pencil. The project champions elicited feedback from the remainder of the NTICU staff. It was determined that the proposed project will be implemented for four weeks. The week prior to project initiation, the project lead performed several educational sessions with NTICU RNs and secretaries to explain the project details and implementation process. Questions were answered and the value to the nurse and patient was reinforced eliciting buy in from team membersDo Stage (Phase)Lewin’s change theory was utilized for this performance improvement project. This type of theory can help to simplify an overall complicated process and has been widely utilized throughout the years.21 The three stages of Lewin’s theory are unfreezing, moving and refreezing.During the unfreezing stage of the project, the current process was assessed for a period of six weeks. Moving from the old method to the new method required ways to unfreeze the current cultural ways of performing shift to shift handoff. Educational opportunities were utilized such as live presentations and evidence based literature review. These methods addressed the need for a swing in culture, understanding the impact to patient safety and improving nurse satisfaction. For the project to be successful two RNs from the team were informal leaders and front line champions. Without frontline champions, the new handoff process may not have been cemented into the daily practice of all of the RNs after the project’s completion. The handoff process might revert back to the previous habits. The project champions were selected based on past performance with quality improvement initiatives and passion for a change in handoff procedures. These key staff RNs assisted in performing the RCA identifying shift to shift handoff barriers.For the moving stage, the project champions along with the project lead initiated the pilot change process. Education on the use of the newly developed SBAR tool was provided to 80 percent of the staff RNs. Due to census and time constraints for project initiation, the tool was not able to be piloted prior to project initiation. During the last stage, the refreezing stage, the newly developed handoff process tool was implemented, tweaked and cemented into practice. The process was monitored to by the project lead to determine adherence to the new process, for feedback and for coaching the new change in culture. RN champions served as mentors for the rest of the team. Weekly staff huddles determined how the process worked at the front line. Concerns were addressed during implementation, rather than at the completion of the project. Lewin’s change theory was complimented by a combination of Relationship-Based Care and Transformational Leadership. It is this style of leadership that develops the team to their maximum ability while mentoring the growth and emergence of new leaders.22 As a transformational leader it was important to demonstrate to the staff why the change is important and involve them in the decision making process. Transformational leaders are effective when they listen to the stakeholders, challenge the norm, influence the process and affirm the process progress.23 In an effort to challenge the norm, resources such as EBP tools were encouraged to be reviewed to promote consistency and structure to the handoff process. Throughout any change development the transformational leader will allow voices to be heard.24 Staff were encouraged to provide feedback on the SBAR tool development. Teamwork was fostered through the group dynamics in creating the new process. A collaborative relationship developed between the project lead and the team coming to a common agreement on the chosen methods determined during the process. Eighteen RNs and six secretaries participated in implementing the NTICU Shift to Shift Handoff Performance Improvement Project along with the nurse manager and project lead. The SBAR tool was initiated by the RN staff for all admissions to NTICU for a period of 30 days. The SBAR tool was made available to all staff at the secretary’s work station. Secretaries ensured that the tool was provided to the RN during the admission process. The tool was printed on yellow cardstock paper for visibility and durability. This helped when the patients had extensive lengths of stay.On the day of project initiation, the project lead along with the nurse manager, met with both shifts at 7am to announce, reinforce the kickoff and answer questions. It was decided that the current patients within the unit would not be included. All patients admitted thereafter to the NTICU had the tool initiated. An iridescent colored educational poster board was displayed on the desk of the nurse’s station for all staff to refer to. It was also a good reminder for initiating the tool. This proved helpful for educating other clinicians about the project and the benefits of the SBAR tool. The project lead was also available for questions and reinforcement.Study Stage (Phase)The process improvement project concluded after four weeks of execution. Project lead observations revealed that nurses were devoted to filling in the SBAR tool on nearly all admissions to the NTICU unit. After careful review of all SBAR tools against the census log of admissions for the four week period, it was noted that 155 of 161 admissions had an SBAR tool initiated. Of these 77 % were completed in its entirety. It was difficult to discern whether nurses kept the tool up to date shift to shift for every day of the patient’s stay. Nurses embraced the new tool for the information that it contained, as nurses exhibited referring to it many times throughout the shift for clarity of patient information. Conversely, during the pilot period, the staff voiced concerns with the value of the tool for the actual handoff process. This was demonstrated behaviorally by the nursing staff frequently needed reminding to gather the tool before starting the handoff report. The project lead and nurse manager frequently reinforced utilizing the SBAR tool for shift report. It was suggested by a night shift RN that the off going shift would pull the SBAR tools in preparation to giving handoff to the oncoming shift. This was ensured routinely by only a few staff who were engaged in the project. Throughout the implementation, the NTICU and organizational cultural norm was identified as a barrier to the new process. Staff were repeatedly urged to adhere to the pilot performance improvement project and asked for suggestions for improvement. It was apparent only a minority of the staff were engaged during observations. After completion of the four week period, a 5 question survey was sent to the RN staff to determined nurse satisfaction and if the SBAR tool enhanced the handoff project. (See figure 4) It was revealed that the staff found the tool to not aide in the handoff process. 90% of the respondents stated that they were completely dissatisfied with the lack of keeping the tool up by each shift. 90% of the respondents also revealed that they were somewhat satisfied with knowing the patients story, but indicated in the comment section when it was kept up to date. Act Stage (Phase)Future projections for the NTICU handoff project is dismal. Without executive support for reactivating the structured handoff project it will not endure. Internal culture and external driving forces played a key factor in the lack of success of this handoff project. Most importantly, the executive leaders of the organization must imbed the concepts of a culture of safety in operational strategies which ensure resources for culture of safety initiatives encompassing all staff, including physicians. 25 All clinicians need to be fully educated on the concepts of a culture of safety and how vital it is to restructure the handoff process. Once this occurs, the newly developed shared governance committees should be actively involved with the development and strategy for insisting that a formalized process be adopted at an organizational level. The shared governance committee and executive leaders should visit Magnet Hospitals to observe practices that are evidence based. It has been demonstrated that process improvement projects that promote a culture of safety are more effective when administrators ascertain processes from organizations of high reliability. 26 Organizations with high reliability for handoff ensure that communication flows dependably. 27Externally, there were many factors that inhibited the success of daily handoff processes. Competing priorities and initiatives took time away from the team and the nurse manager from focusing on ensuring the project moved forward. Additionally, this department was the only area attempting to impact a safe patient handoff. The NTICU nursing staff felt as though it was unfair that the rest of the organization did not have to conform to any structure. This allowed them to not place the importance of the project as a high priority in their nursing practice. Also, fundamental to the project’s success would be to educate all hospital employees that handoff time periods are sacred. Patients should not be transferred during this time period, phone calls should be minimized, procedures should not be scheduled during this timeframe, as well as traffic and noise should be kept to a minimum. It has been revealed that interruptions and distractions can account for an increase in errors. 28One distinction noted is empowering nurses to speak up for safe handoff practices is a necessity. The nursing staff are often frustrated with lack of information provided, however they are unable to channel this energy into actionable changes. They feel inhibited to ask for more information when handoff is inadequate. Many staff feel intimidated to speak up against the cultural norm. The nursing staff must be empowered to say they will not accept a bad report from another individual in the moment. Shared governance structured models often help nurses feel empowered to enhance changes that support patient safety. 28SBAR tool in computer could be instrumental to its success. As it would provide populated information from the care that was performed without the nurses having to write it down. It was apparent from observations as well as survey feedback, that the staff felt as though it was extra work.ConclusionAccurate handoff is essential for safe patient care and for nurses understanding the patient’s story prior to beginning patient care. Although there are strong recommendations to formalize the handoff process, many organizations continue to struggle with implementing these changes. The NTICU attempted to make such a change with a formalized SBAR tool. Despite a well thought out project plan, including an RCA and Lewin’s theory of change the Organizational barriers such as not having an organizational presence of a culture of safety, proved to be the largest barrier to its success. Further work in establishing a genuine culture of safety could prove to be instrumental as well as a Failure Mode and Effect Analysis to ensure the attainment of a structured handoff procedure.References1, 14 Capek J, Wymard-Tomlinson D. Effective communication at change of shift. Nursing Critical Care. 2013;8(1):22-24.2, 19 Joint Commission Center for Transforming Healthcare. 2013. . 2013. Retrieved from ____________Accessed October, 2014.3, 6, 7, 9, 18, 28 Riesenberg L, Leitzsch J, Cunningham JM. Nursing Handoffs: A systematic review of the literature. American Journal of Nursing. 2010;110(4):24-34.4 Agency for Healthcare Research and Quality. Hospital survey on patient safety culture: 2009 comparative report. 2009. Accessed March 2013.5 Holly C, Poletick EB. A systematic review on the transfer of information during nurse transitions in care. Journal of Clinical Nursing. 2013;23:2387-2396. De Vries. Effect of a comprehensive surgical safety system on patient outcomes. New England Journal of Medicine. 2010;363(20):928-37.10, 11 Stevens JD. Implementing standardized reporting and safety checklists: Developing processes to create a culture of safety. American Journal of Nursing. 2011;111(5):48-53.12, 13 Younan LA, Fralic MF. Using “best-fit” interventions to improve the nursing intershift handoff process at a medical center in Lebanon. The Joint Commission Journal on Quality and Patient Safety. 2013;39:460-467.15, 16 Cornell P, Townsend Gervis M. Improving shift report focus and consistency with the situation, background, assessment, recommendation protocol. Journal of Nursing Administration. 2013;43:422-428.17 Agency for Healthcare for Research and Quality. . 2008. Accessed November 2014.20Matney SA, Maddox LJ, Staggers N. Nurses as knowledge workers: Is there evidence of knowledge in patient handoffs? Western Journal of Nursing Research. 2013;36(2):171-190.21 Mitchell G. Selecting the best theory to implement planned change. Nursing Management. 2013;20(1):32-37.22 Koloroutis M. Relationship based care: A model for transforming practice. Minneapolis, MN: Creative Health Care Management 2004.23, 24 Luzinski C. Transformational leadership. The Journal of Nursing Administration. 2011;41(12):501-502.25, 26Yates GR, Bernd DL, Sayles SM, Stockmeier CA, Burke J, Merti GE. Building and sustaining a systemwide culture of safety. The Joint Commission Journal on Quality and Patient Safety. 2005;31(12):684-689.27Halm MA, Nursing handoffs: Ensuring safe passage for patients. American Journal of Critical Care. 2013;22(2):158-162.29Barden AM, Griffin MT, Donahue M, Fitzpatrick JJ. Shared government and empowerment in registered nurses working in a hospital setting. Nursing Administration Quarterly. 2011;35(3):212-218.Figure 1. Root Cause Analysis. CommunicationToolsStaffProcessEnvironmentEducationTimeConstraintsTechnologyInefffective RN to RN Shift HandoffOmissionsLack accountabilitySidebar conversationsCulture AttitudesUnorganizedVariesNo one to enforceNot Evidence BasedAssignmentsIn a hurry to leaveToo longNo OrientationNot clearly defined// No educatorPoor quality InfoSlowNot User friendlyNoisyInterruptionsPatient Needs/AcuityInconsistentOpinionsNo handoff policyCommunicationToolsStaffProcessEnvironmentEducationTimeConstraintsTechnologyInefffective RN to RN Shift HandoffOmissionsLack accountabilitySidebar conversationsCulture AttitudesUnorganizedVariesNo one to enforceNot Evidence BasedAssignmentsIn a hurry to leaveToo longNo OrientationNot clearly defined// No educatorPoor quality InfoSlowNot User friendlyNoisyInterruptionsPatient Needs/AcuityInconsistentOpinionsNo handoff policyFigure 2. Baseline RN SurveyFigure 3. SBAR Handoff ToolNTICU SBAR Patient Information for Handoff Report(To be kept in pts binder and retrieved for report)Diagnosis (Pt story)Admission Date to NTICU:____________________Code Status________****Procedures:Pertinent History:Diet_________________Activity:_____________Abnormal/critical lab values on admission:SCANS/Results:______________________________Current LINES/Tubes/Devices: (Use pencil-keep up to date)Ventilator/ETT_______________________________________Central Line_____ DATE:_____ PICC ______ DATE _______Art Line____________________ DATE:_______JP____________________JP____________________Chest Tubes- R___________ L __________ (Clamps in room?)_____Ventric- R ____________ L ___________Cooling Device________@______ Warming Device__________Foley____________ N/G-O/G_______________OTHER:___________________________________________TPA__________________DPOA:_________________________________Phone:_________________________________Family Dynamics/Concerns:Physician /Pt & Family Plan:Coag Products receivedPRBCs_______________________________________________ FFP___________ Cryo ________ PLTs _____________________Vitamin K_________Please place in the basket at the desk when patient is discharged!PT STICKERReturn form to Marie Wendt Tube 208, SICU if sent to medical recordsFigure 4. Post Implementation RN Survey ................
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