NURS2006 Chronic Illness And Nursing Care

Clinical Practice Improvement Project Report

Project Title:

Clinical Handover Communication using Patient Intervention Comparison (PICO)

Project Aim:

To explore whether using ISOBAR technique for clinical handovers as compared to general verbal technique can help in reducing the percentage of clinical errors in health care settings.

Relevance of Clinical Governance to your project

Clinical governance refers to the framework and criteria employed by the NHS organizations to improve the quality of services offered as well as safeguarding the high standards in medical care through the creation of excellence environment for clinical healthcare. Clinical government is not only limited to the NHS organizations but also entails a practice management and integrated principles which are used in successful dentistry. Clinical handovers mechanisms were introduced in order to reduce the probability of the clinical errors in the medical settings, however in most cases, the concept of clinical handovers are not complied with in an optimal manner (Black et al., 2015). There are many prevalent challenges or issues in the clinical setting involving inadequate usage of clinical handovers, a few key challenges in this situation are:

One of the key issues that have identified in this scenario had been the alarming rate of negative consequences in the care planning and execution for the patients for the lack of proper communication during shift handovers. According to the Boswell et al., 2015, one of the most important factors associated with nursing handovers is the fact that it contains key information regarding the condition of the patient and what principle measures are to be taken while handling that particular patient. In cases where the nursing handover guidelines are not followed properly, the care standards and quality suffers. Elaborating more, the nursing handovers are of crucial importance in the scenarios where the patients need to be relocated to different wards in critical conditions, in situations where the nursing handovers do not contain enough information; the medical complications of the patients have been seen to deteriorate to even life threatening conditions. Hence, not adhering to handover protocols is a direct indication of compromised clinical performance standards (Johnson et al. 2014).

Considering the clinical standards, there are different practices for clinical handover followed, while in some cases bedside handovers are a protocol, in some scenarios the method of informal verbal handovers is followed extensively. However, the verbal handover technique is not just informal but is constitutes chances of major clinical errors. According to the detailed study by authors, it has been discovered that the verbal mode of nursing handovers are extremely inadequate to relay detailed information about the condition of the patient to the attending nurses. Along with that another major concept is the fact that conveying information about the patient cannot complete the authenticity and reliability of a bedside documented nursing handover (Boswell et al., 2015).

Environmental Safety for Staff, Patient and Public is also another essential governance policy which one needs to evaluate in clinical practice and implementation. In fact, the policy outlines that patients have an equal right to clean as well as safe treatment all the time. The system is essential in building the confidence of patients as they receive health care by outlining the set procedures at designated stages in nursing. Thus, Health and Safety at Work Act 1974 form the fundamental grounds for keeping patients safe in the hospital while at the same time helps in protecting workers. Therefore, the policy aims at setting out the responsibilities which the employer has towards both the employees and public as a whole. Additionally, the act also encourages companies in examining workplace risks as well as in coming up with measures of addressing the challenges in return (Mikkonen et al., 2016 p.187).

Fair and manageable care is another key theme which governs clinical care practices. This aims at provide prompt healthcare services as well as gives patients access to treatment. Fair and manageable care is governed by Human Rights Act of 1998, Race Relations and its Amendment Act (2000) and Infirmity Discernment Act 1995. In essence, the Race Relations Act enhances equity and good mutual relations among people of distinct groups.  This includes having access to services to help patients of various ethnicities to make utilization of and completely comprehend the neighbourhood dental administrations accessible. The Human Rights Act covers a scope of political and social equality and the Disability separation act makes it unlawful to oppress a man on the grounds of handicap in the range of business, offices, and administration. An entrance review ought to be done by an outsider to survey current consistency under this demonstration and to acquaint enhancements in access with debilitated patients.

Considering the scope for professional development and management, the issues prevalent in this sector due to improper usage of clinical handovers are many. First and foremost it has to be mentioned nursing is a profession that is absolutely evidence based. And there are many instances where the nursing professionals have to take reasonable clinical decisions where the patients are in need of immediate nursing interventions in critical conditions. These activities do not only broaden the scope of practice for the nursing individual, but also contributes to their professional growth and enhances their ability to handle critical patients. However, these emergency decisions are very crucial, and a single error can cost the patient severely and even lead to penalizing consequences for the nursing professional as well (Clarke and Persaud 2011). According to the Elwyn et al. 2013, the information in the nursing handover is crucial for the shift change nurse to understand the basic care needs of the patients and a general idea of the condition that the patient is in, in case t6hat information is relayed is an inadequate manner, the concept of correct patient assessment and care planning is disrupted. It can also be stated in this context that the incomplete information provided to the nursing professional in the handover can potentially misguide him or her leading to severe consequences. Which further narrows down the scope for professional development of the nursing professional and rather imparts negative effect on the career growth of the person (Elwyn et al. 2013).

Now considering the clinical risks associated with the chosen scenario, there are a multitude of different risks that are prevalent in scenarios where the clinical handovers are either not optimal or are not followed as a regular regime. It has to be understood that the data about the patients regarding vital signs, patient problem, health status, allergic reactions, past medical history, medication charts and risk factors are stated with clarity. In case of verbal handovers, it is impossible for the nursing professional to incorporate each and every intricate detail while communicating with the shift change nurse. Hence, clinical errors like flawed medication administration, hospital acquired infection, fall, allergic manifestations and even cardiac issues can arise. Hence, there had been a need for a standardized technique of maintaining nursing handovers with a protocol to strictly comply  (Flemming and Hübner 2013).

Considering the government initiatives, there have been many steps taken to ensure optimal consumer value while providing safe health care services, however, with the lack of an imperative guidelines or protocol to maintain in handover system that incorporates the importance of traceability of clinical decisions made by the nursing professional communicating the subjective issues of the patient clearly decreases the possibility of the full story of the patient to be shared with the shift change nurse (Boswell et al., 2015).

Evidence that the issue/problem is worth solving:

From the literature search and evaluation, it can be stated that nursing handovers are a necessity, and the nursing handovers should be integrative and detailed, utilized every time the patient is assessed by the nursing professional. That is the reason a few government initiatives have been taken while considering the nursing handover implementation. For instance, the first government initiative regrading standardizing nursing handovers had been the “safe handover: safe patient’ scheme introduced by the British government in the year of 2004 which had been closely followed by Australia and USA around 2007 in the effective “handoffs” scheme (Klim et al. 2013).

Along with that it has to be mentioned that various patterns or frameworks have also been developed in attempt to improve the reliability and authenticity of the nursing handovers. The impact of poor clinical handover is an incapable framework, best case scenario and patient demise even under the least favourable conditions and therapeutic blunders. Clinical handover is critical to guarantee coherence of patient care and patient safety. It serves many capacities and there are many variables that influence clinical handover, and this is why maintaining a standard framework or protocol while maintaining clinical handovers is extremely crucial for providing safe and optimal care to the patient (Kerr et al. 2016).

ISoBAR is one of the most abundantly utilized framework for devising optimal clinical handovers which provides the most scientific and logical tool for making nursing handovers as detailed as possible. It is a mnemonic framework designed for the purpose of improving the patient safety and care quality. The ISoBAR technique or framework has 5 different elements; the first element is identification, where the patient for whom the handover is being prepared is identified (Stanhope and Lancaster 2015). The second section is situation, where the medical complications that the patient is facing at the moment are explained in detail. The third section is background which discusses the past medical history of the patient and the in the fourth section the assessment data of the patient is mentioned in detail. Last section of the tool recommendation where the nursing individual will note down any suggestive intervention which can prove to be helpful in helping the patient overcome whatever health care related complication that has arisen (Graan et al. 2016).

ISOBAR technique is considered to be one of safest techniques for transfer of patent information, and in many of the research studies have proved the efficiency of this tool in devising the nursing handovers that facilitate optimal patient safety and care priorities (Sherwood and Barnsteiner 2017). Rushton et al. 2015 in their cohort analysis study have used the ISOBAR technique for testing out the positive impact of this tool on the efficiency of the bedside handovers and the results indicated that the combination of ISOBAR handovers with verbal communication yielded the best results for reducing clinical errors and improving the patient safety. Hence, for this project, the PDSA activity will also utilize the ISoBAR technique for exploring its impact on the percentage of clinical errors.

The primary stakeholders:

Some of the key stakeholders which one needs to consider in clinical handover communication and implementation include healthcare providers, payers, employers and patients. In fact, it is important to identify the role of each of them before coming up with the framework. Additionally, social environment is also a fundamental factor which one needs to examine while setting up the strategic plan for the implementation process (Moran, Conrad and Burson, 2016).

CPI Tool:

Patient safety proposals in clinical practice and improvement are vital criteria and thus, must follow strict procedures.  This project adheres to the outlined procedures in the Human Service and Health Department of March 2003.

PLAN: The very first activity in this [project will be to plan the entire procedure in a meti9culous manner to ensure that the each and every detail of the planning procedure is taken into consideration. The very first activity is to finalize the heath care setting on which the intervention technique will be carried out. For this project, the health care setting chosen will be acute ward and the bedside handover maintained by the nursing professionals will be strictly based on the ISoBAR template. All the enrolled ward nurses will participate on the study and the project duration will be for two weeks. The data will be collected based on the parameters like, percentage of reduction in the number of clinical errors per shift, the personal feedback from the patients and patient family regarding the safety and quality of care provided, and lastly personal feedback from the nurses regarding the ease in patient takeover during shift changes. Care should be taken to design a well articulated action plan so that each and every parameter of the project is addressed (Lockwood 2016).

DO: the next section of the project will be designing a well articulated action plan so that each and every parameter of the project is addressed. Care should be taken to inform the participants of the project and consent is obtained before progressing with the project. All ethical requirements must also be strictly met during the project taking attention so that the best interests of the patients are not compromised in any manner.

STUDY: The next section of the project as guided by the CPI tool is studying the data collected and analysis of the same data. There are many limitations in the study design that has the potential to introduce significant bias, care should be taken to avoid selection bias as much as possible.

ACT: The last section is associated with documenting project plan and its outcome, it has to be understood that the purpose behind this project had been to explore the benefits of using ISoBAR technique for maintaining bedside handovers while shift change or patient takeover. This project is an excellent tool in determining the extent of positive changes it can bring to the care safety and quality and the possible reduction in the clinical errors. Hence the subjective data gathered and analysis will be documented on this step with a explanative detailed discussion exploring the outcome and arriving at a possible verdict. 

Summary of proposed interventions:

Nursing handover is one of the techniques implemented in the scenario of health acre ease the process of patient takeover and minimise the chances of clinical errors happening due to flawed conveying of subjective and objective data regarding the patients. However verbal handover techniques fail to serve the purpose of safe and authentic transfer of informational data. Hence, there is need for a standardized protocol being used in this scenario so that each and every intricate detail of the patient can be documented and provided to the nurse to whom the patient is being transferred to be cared for (Ouslander et al. 2014). ISoBAR technique is a detailed framework which incorporates all the necessary elements to make the nursing handovers scientific, detailed and reliable. And this intervention technique will be extremely helpful in minimising the percentage of clinical errors that are a direct result of miscommunication of patient information (Piscotty, Kalisch and Gracey?Thomas 2015).

Barriers to implementation and sustaining change:

The obstacles to the critical practices implementations as well as supporting changes mainly summarized below:

Time constraint: The project required an extensive period of time and effort being invested.

Budget: Maintaining a strict ISoBAR format for each and every patient for all shifts will require a strong budget being employed for the project.

Reluctance: Reluctance or lack of compliance in the nursing staff regarding the new technique implemented for handovers has been a significant conflict to overcome.

Evaluation of the project:

The assessment process for this project mainly summarized as posed in the following steps

Identification of the key parameters of decreasing clinical errors in the hospital using ISoBAR approach. Secondly, it is important to evaluate and ascertain all the necessary risks and benefits associated with project.  Thirdly, excitations of the effectiveness of the entire project have to be determined and established. Fourthly, it is also essential to design and evaluate all the utility values and cost effective of the process. Fifthly, intervention approach to all the resulting and emerging issues must be determined and established. Finally, it is important to examine the net cost and healthcare costs connected to adverse events in the clinical implication practices.