![]() The nursing shift change handover process has long been considered to be centrally important to high quality care provision in the hospital setting. ( Staggers and Blaz, 2013) In this study, we sought to identify the historical ‘baseline’ of information content and functions of a nursing report prior to quality improvement interventions that primarily stemmed from hospital accreditation requirements or research conducted on physician sign-outs. In a medical intensive care unit, we anticipated that the following elements might be different for RNs than for internal medicine physicians: use critical thinking to synthesize patients’ care needs from a more holistic perspective ( Hansten, 2003), assess rather than diagnose, assess that the patient is comfortable and that medications have been effective in addressing pain, serve as the central coordination hub of care delivery from many specialists, be the primary person to communicate with patients and family members and educate patients. The context of the unit is also likely to impact content and best practices. In one editorial, Manias and Watson (2014) recommended bedside handovers, greeting the patient, and sitting at eye level during the handover to better involve patients during nursing handovers. Similarly, based on a systematic review, Riesenberg and colleagues (2010) concluded that few research studies have studied best practices in nursing handovers, despite a similarity of recommendations in the literature. A recent ethnographic observational study by Spooner and colleagues (2016) found that the ISBAR mnemonic did not capture all of the information content discussed during nursing handovers. Similarly, Halm (2013) found that only weak (level C) clinical evidence was available to guide the design of nursing handovers in critical care. In addition, Lockwood (2016) found that no randomized controlled trials specific to nurses have been conducted on handovers. Therefore, translating the insights from existing research studies to RNs in a particular care setting can be problematic. Many of the research studies on handover interventions were conducted with resident physicians, such as IPASS (Illness Severity, Patient Summary, Action List, Situation Awareness/Contingency Planning, and Synthesis by Receiver), where the use by internal medicine and pediatric resident physicians was associated with a 23% reduction in medical errors and a 30% reduction in preventable adverse events ( Starmer et al., 2014). Nursing experts play a critical role in developing and updating policies for the nursing handover process at the change of shift a recent example is a bedside handoff model for a postpartum unit which increased both nurse and patient satisfaction ( Wollenhaup et al., 2017). The Joint Commission, in their 2006 National Patient Safety Goal, required “a standardized approach to handoff communications,” and currently this goal is scored as a standard for hospitals ( TJC, 2017). What is the function of verbal report information that is not documented in a patient’s electronic health record? These objectives may guide nursing administrators in tailoring policies and procedures for nursing report to the needs of registered nurses in a critical care setting. Information not typically documented supports providing patient-centered care, sharing clinical judgments, coordinating work, and mentorship. Information is documented in progress notes, the medication administration record, nursing flowsheets, lab results, orders, and past medical history. ![]() Information categories included: Identify patient (51.9%) Narrative history (96.3%) Unusual symptoms (88.9%) Response to care (37%) Status of tasks (100%) Expectations of patients and families (55.6%). Analysis involved unique coding of phrases and emergent themes analysis. This is a descriptive study of 20 reports describing 27 patients from two medical intensive care units. Our objectives are to identify information content in verbal reports, where information is documented, and the function of non-documented communication. Translating validated handover protocols from physicians in non-critical care settings to nursing report in critical care is challenging.
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