"Do You Know What I Know?": How Communication Norms and Recipient Design Shape the Content and Effectiveness of Patient Handoffs.

BACKGROUND: Poor communication during end-of-shift transfers of care (handoffs) is associated with safety risks and patient harm. Despite the common perception that handoffs are largely a one-way transfer of information, researchers have documented that they are complex interactions, guided by implicit social norms and mental frameworks. OBJECTIVES: We investigated communication strategies that resident physicians report deploying to tailor information during face-to-face handoffs that are often based on their implicit inferences about the perceived information needs and potential harm to patients. METHODS/PARTICIPANTS: We interviewed 35 residents in Medicine and Surgery wards at three VA Medical Centers (VAMCs). MAIN MEASURES: We conducted qualitative interviews using audio-recorded semi-structured cognitive task interviews. KEY RESULTS: The effectiveness of handoff communication depends upon three factors: receiver characteristics, type of shift, and patient's condition and perceived acuity. Receiver characteristics, including subjective perceptions about an incoming resident's training or ability levels and their assumed preferences for information (e.g., detailed/comprehensive vs. minimal/"big picture"), influenced content shared during handoffs. Residents handing off to the night team provided more information about patients' medical histories and care plans than residents handing off to the day team, and higher patient acuity merited more detailed information and the medical service(s) involved dictated the types of information conveyed. CONCLUSIONS: We found that handoff communication involves a complex combination of socio-technical information where residents balance relational factors against content and risk. It is not a mechanistic process of merely transferring clinical data but rather is based on learned habits of communication that are context-sensitive and variable, what we refer to as "recipient design." Interventions should focus on raising awareness of times when information is omitted, customized, or expanded based on implicit judgments, the emerging threats such judgments pose to patient care and quality, and the competencies needed to be more explicit in handoff interactions.

Content counts, but context makes the difference in developing expertise: a qualitative study of how residents learn end of shift handoffs.

BACKGROUND: Handoff education is both formal and informal and varies widely across medical school and residency training programs. Despite many efforts to improve clinical handoffs, little evidence has shown meaningful improvement. The objective of this study was to identify residents' perspectives and develop a deeper understanding on the necessary training to conduct safe and effective patient handoffs. METHODS: A qualitative study focused on the analysis of cognitive task interviews targeting end-of-shift handoff experiences with 35 residents from three geographically dispersed VA facilities. The interview data were analyzed using an iterative, consensus-based team approach. Researchers discussed and agreed on code definitions and corresponding case examples. Grounded theory was used to analyze the transcripts. RESULTS: Although some residents report receiving formal training in conducting handoffs (e.g., medical school coursework, resident boot camp/workshops, and handoff debriefing), many residents reported that they were only partially prepared for enacting them as interns. Experiential, practice-based learning (i.e., giving handoffs, covering night shift to match common issues to handoff content) was identified as the most suited and beneficial for delivering effective handoff training. Six skills were described as critical to learning effective handoffs: identifying pertinent information, providing anticipatory guidance, applying acquired clinical knowledge, being concise, incorporating delivery strategies, and appreciating the styles/preferences of handoff recipients. CONCLUSIONS: Residents identified the immersive performance and the experience of covering night shifts as the most important aspects of learning to execute effective handoffs. Formal education alone can miss the critical role of real-time sense-making throughout the process of handing off from one trainee to another. Interventions targeting senior resident mentoring and night shift could positively influence the cognitive and performance capacity for safe, effective handoffs.

Outcomes of Adding Patient and Family Engagement Education to Fall Prevention Bundled Interventions.

Nurses strive to reduce risk and ensure patient safety from falls in health care systems. Patients and their families are able to take a more active role in reducing falls. The focus of this article is on the use of bundled fall prevention interventions highlighted by a patient/family engagement educational video. The implementation of this quality improvement intervention across 2 different patient populations was successful in achieving unit benchmarks.

Nurses' experiences with errors in nursing.

BACKGROUND: Health care organizations seek to maximize the reporting of medical errors to improve patient safety. PURPOSE: This study explored licensed nurses' decision-making with regard to reporting medical errors. METHODS: Grounded theory methods guided the study. Thirty nurses from adult intensive care units were interviewed, and qualitative analysis was used to develop a theoretical framework based on their narratives. DISCUSSION: The theoretical model was titled "Learning Lessons from the Error." The concept of learning lessons was central to the theoretical model. The model included five stages: Being Off-Kilter, Living the Error, Reporting or Telling About the Error, Living the Aftermath, and Lurking in Your Mind. CONCLUSION: This study illuminates the unique experiences of licensed nurses who have made medical errors. The findings can inform initiatives to improve error reporting and to support nurses who have made errors.

Clinical education in nursing: rethinking learning in practice settings.

Clinical education is a time- and resource-intensive aspect of contemporary nursing programs. Despite widespread agreement in the discipline about the centrality of clinical experiences to learning nursing, little is known about if and how current clinical experiences contribute to students' learning and readiness for practice. Before large-scale studies testing specific educational interventionals can be conducted, it is important to understand what currently occurs during clinical experiences. This study, funded by the National Council of State Boards of Nursing, examined the nature of contemporary clinical education by describing students' and faculty's experiences at three geographically diverse universities in the United States. Findings suggest that teachers' and students' focus on task completion persists and often overshadows the more complex aspects of learning nursing practice.

Nurse manager cognitive decision-making amidst stress and work complexity.

AIM: The present study provides insight into nurse manager cognitive decision-making amidst stress and work complexity. BACKGROUND: Little is known about nurse manager decision-making amidst stress and work complexity. Because nurse manager decisions have the potential to impact patient care quality and safety, understanding their decision-making processes is useful for designing supportive interventions. METHODS: This qualitative descriptive study interviewed 21 nurse managers from three hospitals to answer the research question: What decision-making processes do nurse managers utilize to address stressful situations in their nurse manager role? Face-to-face interviews incorporating components of the Critical Decision Method illuminated expert-novice practice differences. Content analysis identified one major theme and three sub-themes. RESULTS: The present study produced a cognitive model that guides nurse manager decision-making related to stressful situations. Experience in the role, organizational context and situation factors influenced nurse manager cognitive decision-making processes. CONCLUSIONS: Study findings suggest that chronic exposure to stress and work complexity negatively affects nurse manager health and their decision-making processes potentially threatening individual, patient and organizational outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: Cognitive decision-making varies based on nurse manager experience and these differences have coaching and mentoring implications. This present study contributes a current understanding of nurse manager decision-making amidst stress and work complexity.

Understanding nurse manager stress and work complexity: factors that make a difference.

OBJECTIVE: This study provided insight into nurse manager stress and coping experiences. BACKGROUND: Overwork and stress have been implicated in today's nursing shortage. Although nurse managers play a pivotal role in creating work environments that retain staff nurses, little is known about nurse manager work. METHODS: This qualitative descriptive study used a sample of 21 nurse managers to determine what situations contribute to their stress, individual coping strategies, and health-related outcomes. Content analysis identified 3 study themes. RESULTS: People and resources, tasks and work volume, and performance expectations affect nurse managers' perceptions of stress. When comparing novice nurse managers with experienced nurse managers, experienced nurse managers (especially comanagers) used more effective (problem focused) coping strategies and had fewer negative health-related outcomes. CONCLUSION: Findings from this study suggest that to impact stress, coping, and complexity in the nurse manager role requires a combination of strategies that address individual and organizational factors.

Barriers and facilitators to nursing handoffs: Recommendations for redesign.

During a handoff, communication errors can lead to adverse events and suboptimal patient care. As a result, many institutions want to redesign their handoff processes, but have little specific guidance from the literature. We examined two approaches to nursing end-of-shift reports both taped and written, to identify specific factors limiting and facilitating such handoffs. Twenty nurses were interviewed using a semistructured format. They were asked about the current reporting process, the limitations, the elements that helped, and ideas for improvement. Analyses revealed that inadequate information, inconsistent quality, limited opportunity to ask questions, equipment malfunction, insufficient time to generate reports, and interruptions, limited handoffs. Facilitators were "pertinent" content, notes and space for notes, face-to-face interaction, and structured form/checklist. Recommendations for redesign are defining content pertinent to the unit, structuring handoffs so that information is received in a standard way, embedding an opportunity for questions into the process, planning for all 3 handoff subprocesses, and conducting peer evaluations and education.

Impact of continuous vigilance monitoring on nursing workflow.

BACKGROUND: Increasing nursing time in patient care is beneficial in improving patient outcomes, but this is proving increasingly difficult with the nursing shortage, budgetary constraints, and higher patient acuity. OBJECTIVE: Nursing workflow was evaluated after the implementation of a continuous vigilance monitoring system to determine if the system enhanced patient-centric nursing care. METHODS: Work sampling observations were conducted at 3 hospitals for 6 categories of nursing activities (direct and indirect nursing, documentation, administrative, housekeeping, and miscellaneous) at baseline and at 3 and 9 months. RESULTS: Statistically significant increases in direct (3 months) and indirect nursing care (3 and 9 months) were found, with variability between sites. Statistically significant increases at 3 and 9 months for documentation of patient care activities and decreases in administrative activities were the most consistent findings for all sites. CONCLUSION: Continuous vigilance monitoring enhanced patient-centric care with increases in direct and indirect nursing care and documentation of those activities.

Voices of chief nursing executives informing a doctor of nursing practice program.

The purpose of this article is to describe the business case framework used to guide doctor of nursing practice (DNP) program enhancements and to discuss methods used to gain chief nurse executives' (CNEs) perspectives for desired curricular and experiential content for doctor of nursing practice nurses in health care system executive roles. Principal results of CNE interview responses were closely aligned to the knowledge, skills and/or attitudes identified by the national leadership organizations. Major conclusions of this article are that curriculum change should include increased emphasis on leadership, implementation science, and translation of evidence into practice methods. Business, information and technology management, policy, and health care law content would also need to be re-balanced to facilitate DNP graduates' health care system level practice.

Implementation Strategies to Improve Knowledge and Adherence to Spinal Cord Injury Guidelines.

PURPOSE: The purpose of this study was to evaluate a bundle of implementation strategies (local opinion leaders, printed educational materials, and educational outreach) to increase neurocritical care nurses' knowledge of and adherence to spinal cord injury guidelines. DESIGN: A preprogram, postprogram, and follow-up design was used to evaluate outcomes. METHODS: Adherence was measured via self-reported anticipatory adherence; knowledge was measured by an author-developed assessment. Repeated-measures ANOVA was used for data analysis. FINDINGS: Improvements in nursing knowledge and adherence were found from preprogram to postprogram to follow-up time points. CONCLUSIONS: Outcomes noted in this study provide additional support for using this bundle of implementation strategies and were consistent with previous research documenting the usefulness of these strategies. CLINICAL RELEVANCE: Although further research is needed, this study highlighted a systematic way of implementing evidence-based practices to improve neurocritical care nurses' knowledge of and adherence to spinal cord injury guidelines.

Bedside Interprofessional Rounding: The View From the Patient's Side of the Bed.

BACKGROUND: Bedside interprofessional rounding is gaining ground as a means to improve collaboration and patient outcomes, yet little is known regarding patients' perceptions of the practice. METHODS: This descriptive study used individual patient interviews to elicit views on interprofessional rounding from 35 patients at a large, urban hospital. RESULTS: The findings identified three major categories: 1) about the rounding process; 2) clinical information; and 3) the impact/value of bedside inter-professional rounding. DISCUSSION: Intentionally eliciting and responding to our patients' views of interprofessional rounding may help us design methods that are patient centered and effective.

Program evaluation of neuroscience competency programs to implement evidence-based practices.

RATIONALE: Program evaluation is essential to help determine the success of an evidence-based practice program and assist with translating these processes across settings. AIMS: The purpose of this study was to evaluate the usefulness of 2 competency programs that sought to improve neurocritical care nurses' knowledge of and adherence to evidence-based stroke and spinal cord injury guidelines. These programs consisted of 3 specific implementation strategies, including local opinion leaders, printed educational materials, and educational outreach. METHODS: A qualitative study using one-on-one interviews with 10 neurocritical care nurses was used. Semi-structured interview questions examined the nurses' perceptions of the competency programs and the implementation strategies used; themes were identified through first-level coding. The transcripts were deductively analyzed and categorized using a predetermined implementation outcomes framework, including the concepts of acceptability, appropriateness, adoption, and sustainability. RESULTS: Nurses reported that the 3 implementation strategies used for the competency programs were acceptable and appropriate. Further, the nurses perceived that the evidence-based practices reviewed during the programs were being adopted into practice and provided suggestions for sustaining improvements in nursing knowledge of and adherence to these evidence-based practices. CONCLUSIONS: Findings from this study support the success of the Stroke and Spinal Cord Injury Competency Programs, as well as the usefulness of the 3 implementation strategies used. This study provides insight for improvements for subsequent studies focused on implementing evidence-based practices.

"Mr Smith's been our problem child today ": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs.

BACKGROUND: Tools and procedures designed to improve end-of-shift handoffs through standardisation of processes and reliance on technology may miss contextually sensitive information about anticipated events that emerges during face-to-face handoff interactions. Such information, what we refer to as anticipatory management communication (AMC), is necessary to ensure timely and safe patient care, but has been little studied and understood. OBJECTIVE: To investigate AMC and the role it plays in nursing and medicine handoffs. RESEARCH DESIGN: Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical intern-to-intern handoffs. SUBJECTS: 27 nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center. RESULTS: Heads-up information was the most frequent type of AMC across all handoff dyads (N=257; 108 resident and 149 nursing). Indirect instructions AMC was used in a little over half the resident handoff dyads, but occurred in all nursing dyads (292 instances). Direct instructions AMC occurred in roughly equal proportion across all dyads but at a modest frequency (N=45; 28 resident and 17 nursing). Direct (if/then) contingency AMC occurred in resident handoffs more frequently than in nursing handoffs (N=32; 30 resident and 2 nursing). CONCLUSIONS: The different frequencies for types of AMC likely reflect differences in how residents and nurses work and disparate professional cultures. But, verbal communication in both groups included important information unlikely to be captured in written handoff tools or the electronic medical record, underscoring the importance of direct communication to ensure safe handoffs.

"Anybody on this list that you're more worried about?" Qualitative analysis exploring the functions of questions during end of shift handoffs.

BACKGROUND: Shift change handoffs are known to be a point of vulnerability in the quality, safety and outcomes of healthcare. Despite numerous efforts to improve handoff reliability, few interventions have produced lasting change. Although the opportunity to ask questions during patient handoff has been required by some regulatory bodies, the function of questions during handoff has been less well explored and understood. OBJECTIVE: To investigate questions and the functions they serve in nursing and medicine handoffs. RESEARCH DESIGN: Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical intern-to-intern handoffs. SUBJECTS: Twenty-seven nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center. RESULTS: Our analysis revealed that the vast majority of questions were asked by the Incoming Providers. Although topics varied widely, the bulk of Incoming Provider questions requested information that would best help them understand individual patient conditions and plan accordingly. Other question types sought consensus on clinical reasoning or framing and alignment between the two professionals. CONCLUSIONS: Handoffs are a type of socially constructed work. Questions emerge with some frequency in virtually all handoffs but not in a linear or predictable way. Instead, they arise in the moment, as necessary, and without preplanning. A checklist cannot model this process element because it is a static memory aid and questions occur in a relational context that is emergent. Studying the different functions of questions during end of shift handoffs provides insights into the interface between the technical context in which information is transferred and the social context in which meaning is created.

Nurse Manager Behaviors That RNs Perceive to Affect Their Job Satisfaction.

PURPOSE: Nurse manager behaviors and job satisfaction are commonly addressed in the literature; however, registered nurse (RN) perceptions of nurse manager behaviors provide a unique perspective that may inform future strategies designed to enhance RN job satisfaction. In this paper, the perceptions of RNs were explored through focus groups to learn the behaviors of nurse managers that most influence RNs' job satisfaction. METHODS: Five focus groups were conducted through semi-structured interviews of a total of 28 RNs to provide data that were coded through qualitative content analysis for themes. FINDINGS: The findings provide nurse managers with data related to the perceptions of RNs and the behaviors of managers that influence job satisfaction. The findings identified two conceptual categories of RN perceptions of nurse manager behaviors: manager behaviors supportive of RNs (communication, respect, and feeling cared for) plus the RNs' perceived disconnect of work issues from the manager's role. CONCLUSION: Findings support past research in relation to the perceptions of RNs wanting to be respected, included in communication, and the need to feel cared for by nurse managers to have higher levels of job satisfaction.

The "New Look" approach to patient safety: a guide for clinical nurse specialist leadership.

This article describes a complex system model based on human performance factors that is borrowed from other industries but can be used by clinical nurse specialists for making progress in patient safety. Traditional approaches to investigation and follow-up of errors in healthcare organizations have not resulted in improvement in patient safety. The New Look approach described in this article emphasizes the complexity in which healthcare workers make decisions about patient c are every day and how increased learning about the resiliency of healthcare workers in the face of multiple system gaps and discontinuities will lead to long-lasting improvements in safety. The article describes how the clinical nurse specialist can lead efforts using the New Look human performance-based approach in 4 areas: changing to a nonpunitive culture, learning about system complexity, learning about healthcare worker resiliency, and preparing for the complexity of introducing change.

Situation Awareness and Interruption Handling During Medication Administration.

Medication administration error remains a leading cause of preventable death. A gap exists in understanding attentional dynamics, such as nurse situation awareness (SA) while managing interruptions during medication administration. The aim was to describe SA during medication administration and interruption handling strategies. A cross-sectional, descriptive design was used. Cognitive task analysis (CTA) methods informed analysis of 230 interruptions. Themes were analyzed by SA level. The nature of the stimuli noticed emerged as a Level 1 theme, in contrast to themes of uncertainty, relevance, and expectations (Level 2 themes). Projected or anticipated interventions (Level 3 themes) reflected workload balance between team and patient foregrounds. The prevalence of cognitive time-sharing during the medication administration process was remarkable. Findings substantiated the importance of the concept of SA within nursing as well as the contribution of CTA in understanding the cognitive work of nursing during medication administration.

Advancing the science of research in nursing education: contributions of the critical decision method.

Advancing the science of nursing education will require the discipline to conduct research that investigates complex phenomena, such as students' clinical thinking and decision-making skills, using multiple methods. The research methods developed in other disciplines can provide nursing education researchers with new ways to investigate clinical teaching and learning in nursing. The critical decision method (CDM), derived from psychology and human factors engineering, is a technique by which researchers elicit experts' thinking and the cognitive work informing decision making in the context of practice. This article describes how the CDM was adapted to study nursing students' situation awareness, cues for action, and pattern recognition during clinical experiences. The CDM is a promising method for investigators to use to conduct research in nursing education and to inform the design of clinical experiences to promote these critical abilities.

Understanding situation awareness in nursing work: a hybrid concept analysis.

Eighty percent of medical error are attributed to human factors. Human factors experts suggest the least explored factor in patient errors is attention, specifically, situation awareness. The purpose of this article was to analyze the concept of situation awareness using a hybrid concept analysis. The experience of situation awareness among nurses was elicited during the fieldwork phase through semistructured interviews. Content and relational analyses yielded 9 themes: perception, comprehension, projection, knowledge and expertise, cognitive overload, interruption management, task management, instantaneous learning, and cognitive stacking. A conceptual definition of situation awareness emerged along with recommendations for application in nursing.