Implementing a ward-level intervention to improve nursing handover communication with a focus on bedside handover-A qualitative study.

AIM: To improve the effectiveness of nursing clinical handover through a qualitative, tailored communication intervention. DESIGN: A multisite before and after intervention using qualitative ethnography combined with discourse analysis of nursing handover interactions. METHODS: We implemented a tailored ward-based intervention to redesign nursing handover practice with co-constructed recommendations for organisational and cultural change on seven wards across three affiliated metropolitan hospitals between February 2020 and November 2022. The intervention was informed by pre-implementation interviews and focus groups with nursing, medical and allied health staff and patients (n = 151) and observed and/or audio-recorded handover events (n = 233). Post-intervention we conducted interviews and focus groups (n = 79) and observed and/or audio-recorded handover events (n = 129) to qualitatively evaluate impact. RESULTS: Our translational approach resulted in substantial changes post-intervention. Nurses conducted more shift-to-shift handovers at the bedside, with greater patient interaction and better structured and more comprehensive information transfer, supported by revised handover documentation. Redesigned group handovers were focused and efficient, communicating critical patient information. CONCLUSION: Contextualised training combined with changes to ward-level systemic factors impeding communication results in improved nursing handovers. Practice change requires strong executive leadership and project governance, combined with effective ward-level leadership, collaboration and mentoring. The speed and degree of change post-intervention demonstrates the power of interdisciplinary collaborative research between hospital executive, ward leadership and communication specialists. RELEVANCE TO CLINICAL PRACTICE: Nurses are more likely to conduct efficient group handovers and informative, patient-centred bedside handovers in line with policy when they understand the value of handover and have practical strategies to support communication. Communication training should be combined with broader ward-level changes to handover practice tailored to the ward context. A multilevel approach results in more effective practice change. REPORTING METHOD: We adhered to the COREQ guidelines. PATIENT OR PUBLIC CONTRIBUTION: We interviewed patients on study wards pre and post intervention.

The ACCELERATE Plus (assessment and communication excellence for safe patient outcomes) Trial Protocol: a stepped-wedge cluster randomised trial, cost-benefit analysis, and process evaluation.

BACKGROUND: Nurses play an essential role in patient safety. Inadequate nursing physical assessment and communication in handover practices are associated with increased patient deterioration, falls and pressure injuries. Despite internationally implemented rapid response systems, falls and pressure injury reduction strategies, and recommendations to conduct clinical handovers at patients' bedside, adverse events persist. This trial aims to evaluate the effectiveness, implementation, and cost-benefit of an externally facilitated, nurse-led intervention delivered at the ward level for core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication. We hypothesise the trial will reduce medical emergency team calls, unplanned intensive care unit admissions, falls and pressure injuries. METHODS: A stepped-wedge cluster randomised trial will be conducted over 52 weeks. The intervention consists of a nursing core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication and will be implemented in 24 wards across eight hospitals. The intervention will use theoretically informed implementation strategies for changing clinician behaviour, consisting of: nursing executive site engagement; a train-the-trainer model for cascading facilitation; embedded site leads; nursing unit manager leadership training; nursing and medical ward-level clinical champions; ward nurses' education workshops; intervention tailoring; and reminders. The primary outcome will be a composite measure of medical emergency team calls (rapid response calls and 'Code Blue' calls), unplanned intensive care unit admissions, in-hospital falls and hospital-acquired pressure injuries; these measures individually will also form secondary outcomes. Other secondary outcomes are: i) patient-reported experience measures of receiving safe and patient-centred care, ii) nurses' perceptions of barriers to physical assessment, readiness to change, and staff engagement, and iii) nurses' and medical officers' perceptions of safety culture and interprofessional collaboration. Primary outcome data will be collected for the trial duration, and secondary outcome surveys will be collected prior to each step and at trial conclusion. A cost-benefit analysis and post-trial process evaluation will also be undertaken. DISCUSSION: If effective, this intervention has the potential to improve nursing care, reduce patient harm and improve patient outcomes. The evidence-based implementation strategy has been designed to be embedded within existing hospital workforces; if cost-effective, it will be readily translatable to other hospitals nationally. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ID: ACTRN12622000155796. Date registered: 31/01/2022.

Improving patient-centred care through a tailored intervention addressing nursing clinical handover communication in its organizational and cultural context.

AIMS: To increase the quality and safety of patient care, many hospitals have mandated that nursing clinical handover occur at the patient's bedside. This study aims to improve the patient-centredness of nursing handover by addressing the communication challenges of bedside handover and the organizational and cultural practices that shape handover. DESIGN: Qualitative linguistic ethnographic design combining discourse analysis of actual handover interactions and interviews and focus groups before and after a tailored intervention. METHODS: Pre-intervention we conducted interviews with nursing, medical and allied health staff (n = 14) and focus groups with nurses and students (n = 13) in one hospital's Rehabilitation ward. We recorded handovers (n = 16) and multidisciplinary team huddles (n = 3). An intervention of communication training and recommendations for organizational and cultural change was delivered to staff and championed by ward management. After the intervention we interviewed nurses and recorded and analyzed handovers. Data were collected from February to August 2020. Ward management collected hospital-acquired complication data. RESULTS: Notable changes post-intervention included a shift to involve patients in bedside handovers, improved ward-level communication and culture, and an associated decrease in reported hospital-acquired complications. CONCLUSIONS: Effective change in handover practices is achieved through communication training combined with redesign of local practices inhibiting patient-centred handovers. Strong leadership to champion change, ongoing mentoring and reinforcement of new practices, and collaboration with nurses throughout the change process were critical to success. IMPACT: Ineffective communication during handover jeopardizes patient safety and limits patient involvement. Our targeted, locally designed communication intervention significantly improved handover practices and patient involvement through the use of informational and interactional protocols, and redesigned handover tools and meetings. Our approach promoted a ward culture that prioritizes patient-centred care and patient safety. This innovative intervention resulted in an associated decrease in hospital-acquired complications. The intervention has been rolled out to a further five wards across two hospitals.

Clinicians' accounts of communication with patients in end-of-life care contexts: A systematic review.

OBJECTIVE: Communication between patients and end-of-life care providers requires sensitivity given the context and complexity involved. This systematic review uses a narrative approach to synthesise clinicians' understandings of communication in end-of-life care. METHODS: A systematic, narrative synthesis approach was adopted given the heterogeneity across the 83 included studies. The review was registered prospectively on PROSPERO (ID: CRD42019125155). Medline was searched for all articles catalogued with the MeSH terms "palliative care," "terminal care" or "end-of-life care," and "communication". Articles were assessed for quality using a modified JQI-QARI tool. RESULTS: The findings highlight the centrality and complexity of communication in end-of-life care. The challenges identified by clinicians in relation to such communication include the development of skills necessary, complexity of interpersonal interactions, and ways in which organisational factors impact upon communication. Clinicians are also aware of the need to develop strategies for interdisciplinary teams to improve communication. CONCLUSION: Training needs for effective communication in end-of-life contexts are not currently being met. PRACTICE IMPLICATIONS: Clinicians need more training to address the lack of skills to overcome interactional difficulties. Attention is also needed to address issues in the organisational contexts in which such communication occurs.