Nurses' experience of handoffs on four Canadian medical and surgical units: A shared accountability for knowing and safeguarding the patient.

AIMS: To explore nurses' experience and describe how they manage various contextual factors affecting the nurse-to-nurse handoff at change of shift. DESIGN: Qualitative descriptive study. METHODS: A convenience sample of 51 nurses from four medical and surgical care units at a university-affiliated hospital in Montreal, Canada, participated in one of the 19 focus group interviews from November 2017 to January 2018. Data were analysed through a continuous and iterative process of thematic analysis. RESULTS: Analysis of the data generated a core theme of 'sharing accountability for knowing and safeguarding the patient' that is achieved through actions related to nurses' role in the exchange. Specifically, the outgoing nurse takes actions to ensure continuity of care when letting go, and the incoming nurse takes actions to provide seamless care when taking over. In both roles, nurses navigate each handoff juncture by mutually adjusting, ensuring attentiveness, managing judgements, keeping on track, and venting and debriefing. Handoff is also shaped by contextual conditions related to handoff norms and practices, the nursing environment, individual nurse attributes and patient characteristics. CONCLUSIONS: This study generated a conceptualization of nurses' roles and experience that details the relationship among the elements and conditions that shape nurse-to-nurse handoffs. IMPACT: Nursing handoff involves the communication of patient information and relational behaviours that support the exchange. Although many factors are known to influence handoffs, little was known about nurses' experience of dealing with these at the point of care. This study contributed a comprehensive conceptualization of nursing handoff that could be useful in identifying areas for quality improvement and guiding future educational efforts.

Nursing handoffs and clinical judgments regarding patient risk of deterioration: A mixed-methods study.

AIMS AND OBJECTIVES: To explore how change-of-shift handoffs relate to nurses' clinical judgments regarding patient risk of deterioration. BACKGROUND: The transfer of responsibility for patients' care comes with an exchange of information about their condition during change-of-shift handoff. However, it is unclear how this exchange affects nurses' clinical judgments regarding patient risk of deterioration. DESIGN: A sequential explanatory mixed-methods study reported according to the STROBE and COREQ guidelines. METHODS: Over four months, 62 nurses from one surgical and two medical units at a single Canadian hospital recorded their handoffs at change of shift. After each handoff, the two nurses involved each rated the patient's risk of experiencing cardiac arrest or being transferred to an intensive care unit in the next 24 hr separately. The information shared in handoffs was subjected to content analysis; code frequencies were contrasted per nurses' ratings of patient risk to identify characteristics of information that facilitated or hindered nurses' agreement. RESULTS: Out of 444 recorded handoffs, there were 125 in which at least one nurse judged that a patient was at risk of deterioration; nurses agreed in 32 cases (25.6%) and disagreed in 93 (74.4%). These handoffs generally included information on abnormal vital signs, breathing problems, chest pain, alteration of mental status or neurological symptoms. However, the quantity and seriousness of clinical cues, recent transfers from intensive care units, pain without a clear cause, signs of delirium and nurses' knowledge of patient were found to affect nurses' agreement. CONCLUSIONS: Nurses exchanged more information regarding known indicators of deterioration in handoffs when they judged that patients were at risk. Disagreements most often involved incoming nurses rating patient risk as higher. RELEVANCE TO CLINICAL PRACTICE: This study suggests a need to sensitise nurses to the impact of certain cues at report on their colleagues' subsequent clinical judgments. Low levels of agreement between nurses underscore the importance of exchanging impressions regarding the likely evolution of a patient's situation to promote continuity of care.

A web-based tailored nursing intervention (TAVIE en m@rche) aimed at increasing walking after an acute coronary syndrome: Multicentre randomized trial.

AIM: Evaluate a web-based tailored nursing intervention, TAVIE en m@rche, on increasing daily steps after an acute coronary syndrome. DESIGN: Parallel two-group multicentre randomized trial. METHODS: An experimental group receiving TAVIE en m@rche, was compared to  a control group receiving hyperlinks to public websites. Acute coronary syndrome patients who were insufficiently active were recruited from three coronary care units. Daily steps at 12 weeks were the primary outcome. Secondary outcomes included self-reported walking and moderate to vigorous physical activity (MVPA). Exploratory outcomes were angina frequency, emergency department visits, hospitalizations and secondary prevention programme attendance. RESULTS: Primary data were analysed for 39 participants. No significant effects were found. At 12 weeks 275.9 more daily steps and 1,464.3 more energy expenditure in MVPA were found in the experimental group relative to the control. No effects were found for angina frequency, emergency department visits, hospitalizations and secondary prevention programme attendance. CONCLUSION: The lack of effect on our primary result may be explained by the intervention goal that was mismatched to the needs of our mostly sufficiently active sample at randomization, resulting in no meaningful change in daily steps. Although the non-significantly greater increase in self-reported MVPA may represent gains in health among the participants that accessed TAVIE en m@rche, this result should be interpreted with caution. IMPACT: From 40%-60% of acute coronary syndrome patients self-report insufficient levels of physical activity. No effect was found on the primary outcome of daily steps. Although not significant, a greater increase in MVPA was found at 12 weeks. The primary outcome can be explained by most of the sample having attained the physical activity recommendation at randomization. Caution in interpreting the non-significant increase in MVPA is warranted due to attrition bias and statistical uncertainty. Future directions may consider the timing of randomization in relation to meeting the needs of insufficiently active acute coronary syndrome patients.

Intentional partnering: a grounded theory study on developing effective partnerships among nurse and physician managers as they co-lead in an evolving healthcare system.

AIM: The aim of this study was to describe the process of how nurse and physician managers in formalized dyads work together to address clinical management issues in the surgical division of one hospital setting. BACKGROUND: Nurse and physician managers are uniquely positioned to co-lead and transform healthcare delivery. However, little is known about how this management dyad functions in the healthcare setting. DESIGN: A constructivist grounded theory approach was used to investigate the process of how nurse and physician managers work together in formalized dyads in an urban Canadian university affiliated teaching hospital. METHODS: Data collection occurred from September 2013-August 2014. Data included participant observation (n = 142 hours) and intensive interviews (n = 36) with nurse-physician manager dyads (12 nurses, 9 physicians) collected in a surgical department. Theoretical sampling was used to elaborate on properties of emerging concepts and categories. RESULTS/FINDINGS: A substantive theory on 'intentional partnering' was generated. Nurses' and physicians' professional agendas, which included their interests and purposes for working with each other served as the starting point of 'intentional partnering'. The theory explains how nurse and physician managers align their professional agendas through the processes of 'accepting mutual necessity', 'daring to risk (together)' and 'constructing a shared responsibility'. Being credible, earning trust and safeguarding respect were fundamental to communicating effectively. CONCLUSION: Intentional partnering elucidates the relational components of working together and the strategizing that occurs as each partner deliberates on what he or she is willing to accept, risk and put into place to reap the benefits of collaborating.

Colorectal surgery patients' pain status, activities, satisfaction, and beliefs about pain and pain management.

This study describes surgical colorectal cancer patients' pain levels, recovery activities, beliefs and expectations about pain, and satisfaction with pain management. A convenience sample of 50 adult inpatients who underwent colorectal surgery for cancer participated. Patients were administered the modified American Pain Society Patient Outcome Questionnaire on postoperative day 2 and asked to report on their status in the preceding 24 hours. Patients reported low current (mean 1.70) and average (mean 2.96) pain scores but had higher scores and greater variation for worst pain (mean 5.48). Worst pain occurred mainly while turning in bed or mobilizing, and 25% of patients experienced their worst pain at rest. Overall, patients expected to have pain after surgery and were very satisfied with pain management. Patients with worst pain scores >7 reported interference with recovery activities, mainly general activity (mean 5.67) and walking ability (mean 5.15). These patients were likely to believe that "people can get addicted to pain medication easily" (mean 3.39 out of 5) and that "pain medication should be saved for cases where pain gets worse" (mean 3.20 out of 5). These beliefs could deter patients from seeking pain relief and may need to be identified and addressed along with expectations about pain in the preoperative nursing assessment.

Bridging the transition from hospital to home: effects of the VITAL telehealth program on recovery for CABG surgery patients and their caregivers.

The purpose of this randomized trial was to determine whether coronary artery bypass graft surgery patients and their caregivers who received telehealth follow-up had greater improvements in anxiety levels from pre-surgery to 3 weeks after discharge than did those who received standard care. Secondary outcomes included changes in depressive symptoms and patients' contacts with physicians. No group differences were noted in changes in patients' anxiety and depressive symptoms, but patients in the telehealth group had fewer physician contacts (p = .04). Female caregivers in the telehealth group had greater decreases in anxiety than those in standard care (p < .001), and caregivers of both genders in the telehealth group had greater decreases in depressive symptoms (p = .03).

Caregiving appraisal and disease activity in early inflammatory arthritis.

OBJECTIVE: The caregiving process accompanying inflammatory arthritis can be stressful to both caregivers and care recipients. In this study, we examined how caregiving involvement and caregiving appraisal as perceived by both patients and their caregiving spouses relate to disease activity and mental health of patients in early inflammatory arthritis. METHODS: Patients in the early phase (> 6 weeks, <18 months duration) of inflammatory arthritis were recruited from a larger early inflammatory arthritis registry, which recorded sociodemographic data and disease characteristics. Disease activity was measured with the Disease Activity Score in 28 joints (DAS28). Current depressive symptoms were measured using the Center for Epidemiologic Studies - Depression Mood Scale. Patient and spouse perceived caregiving involvement and caregiving appraisal were assessed using the Caregiving Involvement Questionnaire and Caregiving Appraisal Scale, respectively. RESULTS: The study sample consisted of 73 patients living with spouse. Mean age was 54 years, 64.4% were women and mean illness duration was 7.48 months. Patients' positive caregiving appraisal was associated with less disease activity (DAS28) (p = 0.003) and less total depressive mood (p < 0.001). In multivariate analysis, patients' appraisal of the caregiving context was negatively associated with disease activity (DAS28) after controlling for caregiving involvement and depression (p = 0.035). CONCLUSION: This study indicates that, in early inflammatory arthritis, patients' caregiving appraisal might be important to consider when assessing disease activity. Clinicians are encouraged to include both patients and their spouse caregivers in interventions.

Exploring the nature of facilitating interprofessional learning: findings from an exploratory study.

With the growing complexity in managing multiple disease and illness-related problems, increased attention is being paid to the importance of interprofessional education (IPE) in preparing students for working collaboratively with different professionals. Educational activities for mixed groups of health professional students are increasing, and facilitation of learning in interprofessional student groups is now acknowledged as an essential part of successful interprofessional learning activities. However, little is known about the strategies used by facilitators with students from different professions, and how they promote learning. Using data obtained through an analysis of videos taken as part of a large study of IPE and interprofessional practice, this study aimed to identify the pedagogical strategies and behaviours of facilitators participating in seven different learning activities with health care students from five different professions. The data captured student reactions and behaviours and provided insight into the dynamics of the interprofessional encounters. The findings showed that facilitating groups involved a complex interchange of three types of interaction between facilitators and students: facilitator-controlled interaction, facilitator-driven interaction and student-driven interactions. The findings also suggest that faculty development programs should assist facilitators to re-examine teaching approaches and encourage students to assume the responsibility for discussing issues and collaborating with others in all their interprofessional contacts. Continuity and stability in faculty development activities will better prepare clinical educators and young professionals to become interprofessional champions.

Cardiac surgery discharge questionnaires: meeting information needs of patients and families.

Tailoring discharge teaching information to the unique learning needs of cardiac surgery patients and their caregivers may improve information acquisition and retention and positively influence the transition home for these individuals. Two questionnaires were developed, one for adult cardiac surgery patients, and one for their caregivers, to explore their self-identified information needs regarding discharge teaching information. The questionnaires were adapted from the Patient Learning Needs Scale of Bubela et al. (1990). The content of the questionnaires was based on informal discussions with patients and their caregivers and nurses of the cardiac surgery department of a university teaching hospital. In addition, previous research exploring discharge teaching content post cardiac surgery and perceived discharge information needs of this population was reviewed. Preliminary testing of the tools indicated content validity. The questionnaires may enhance the efficiency and quality of discharge teaching, as they enable nurses to address the unique information needs of patients and caregivers. This, in turn, may assist patients and caregivers to cope with the transition home. Formal piloting and evaluation of the tools with all stakeholder groups is indicated, in order to determine the effectiveness of the questionnaires and to evaluate and validate their content and format.

Perceptions of a peer learning approach to pediatric clinical education.

With changing trends in the acute pediatric setting, there is concern that nursing students are not provided with sufficient opportunities to develop required clinical competencies. Peer learning can assist students in achieving learning objectives through efficient and effective use of limited resources. In this study the perceptions of students and clinical instructors in their use of peer learning are described. A qualitative descriptive design with semi-structured interviews was used. A convenience sample included nursing students (n=10) and clinical instructors (n=2). Participants had overall positive experiences with formalized peer learning. The novelty of a learning approach, support, communication and the facilitation of learning were the common emerging main themes; with several subthemes also identified. The results highlighted how the learning process was influenced by the students' status as novice nurses and how peer learning provided much needed emotional and physical support. Implications for clinical education are discussed.

Nurses' judgments of patient risk of deterioration at change-of-shift handoff: Agreement between nurses and comparison with early warning scores.

BACKGROUND: Nurses begin forming judgments regarding patients' clinical stability during change-of-shift handoffs. OBJECTIVES: To examine the agreement between incoming and outgoing nurses' judgments of deterioration risk following handoff and compare these judgments to commonly used early warning scores (MEWS, NEWS, ViEWS). METHODS: Following handoffs on three medical/surgical units, nurses completed the Patient Acuity Rating. Nurse ratings were compared with computed early warning scores based on clinical data. In follow-up interviews, nurses were invited to describe their experiences of using the rating scale. RESULTS: Sixty-two nurses carried out 444 handoffs for 158 patients. While the agreement between incoming and outgoing nurses was fair, correlations with early warning scores were low. Nurses struggled with predicting risk and used their impressions of differential risk across all the patients to whom they had been assigned to arrive at their ratings. CONCLUSION: Nurses shared information that influenced their clinical judgments at handoff; not all of these cues may necessarily be captured in early warning scores.

A quality end of life from a palliative care patient's perspective.

This qualitative study explored the meaning of quality of life (QOL) from the perspective of palliative care patients by examining their lived experiences and their perceptions of what contributes to their QOL. Ten in-patients--five women and five men--took part in in-depth, semi-structured interviews. When asked about their QOL, they spoke about three distinct aspects: the meaning of a quality life at this stage in their illness trajectory, the experience of living with the illness, and factors that contributed to their QOL. Patients' approach to life, illness life, and ideal quality life were found to create a sphere of influence that shaped their end-of-life experience. At the heart of living a quality end of life for these patients was their ability to "do the things that I usually do," "be helpful to others," and "live in a caring environment," The findings highlight the importance of understanding each of these factors: patients' approach to life, illness life, and ideal quality of life, and what they mean to patients in order to tailor interventions to enhance their QOL.

The importance of piloting an RCT intervention.

The pilot study provides a unique opportunity to identify and prepare for the challenges of evaluating an intervention. Ultimately, it will enhance the scientific rigour and value of the full-scale study. Although some journals publish reports of pilot studies, little attention has been given to the types of research questions and issues specific to these studies. This article focuses on the utility of a pilot randomized controlled trial (RCT) as a first step towards conducting an RCT. Three major objectives of a pilot RCT are discussed: assessing the feasibility and acceptability of the intervention, assessing the feasibility and acceptability of the design and procedures, and facilitating the determination of effect sizes for use in sample-size calculations.

Factors influencing the use and nonuse of continuous positive airway pressure therapy: a comparative case study.

The rates of sustained use of continuous positive airway pressure (CPAP) therapy among adults with obstructive sleep apnea (OSA) appear consistently suboptimal, despite the efficacy of this treatment. Using semistructured interviews, this study identified facilitators and barriers toward CPAP therapy after treatment initiation among patients with OSA. A purposive sample of eight patients representing extreme differences in CPAP use was recruited from a multisite sleep disorders clinic at a tertiary health center. Perceived physical, psychological, and social factors were found to influence both CPAP use and nonuse. It was revealed that the way patients feel about themselves influences the ways in which they manage their OSA with or without CPAP This study underlines the necessity of working with patients and their families to create social environments that are both accepting and supportive of patients with OSA.

Perceptions of risk for foot problems and foot care practices of patients on hemodialysis.

Patients with end stage renal disease are recognized as being prone to foot problems; however, less is known about this issue from the patient's perspective. This qualitative descriptive study explored the perceptions of risk for foot problems and foot care practices of patients on hemodialysis. A purposive sample of 9 men and women from a large university-affiliated hospital center in Quebec, Canada, was used. Three major themes emerged from the semi-structured interviews: 1) Foot problems are not a serious complication, 2) I am protected from developing foot problems, and 3) Taking care of my feet. Patients, including those currently suffering from a foot problem, lacked knowledge of their actual risk for foot problems. All participants engaged in some form of foot care, such as the use of a foot bath and regular moisturizing. Several individuals described behaviors that could compromise foot health. Findings suggest that it is worthwhile for nurses to elicit patients' actual foot care practices to validate those that are appropriate and to address those that are unsafe.

Toward Resilient Nurse Leaders: The Leadership-In-Action Program in Nursing (LEAP-IN).

Leadership is a critical component of health system performance. This paper describes a tailored leadership development program for nurse managers in an academic health network in Montreal, Canada, developed in collaboration with a university school of continuing studies. This program is aimed toward strengthening individual leadership competencies and developing a resilient nursing leadership community of practice. In total, 26 nurse managers across the health network participated in the program. Senior nurse directors participated by facilitating group discussions with the nurse managers. Program content was developed through a participative process and in direct response to senior leadership participation through online surveys, interviews and focus groups. An experiential learning approach was used to analyze incidents, explore problems and develop projects specific to the learners' context. The present paper describes the development of this program, outlines plans for evaluation and discusses the lessons learned throughout this process.

A "basket of care" for heart failure patients managing at home: evaluating a community-based nursing intervention from a patient's perspective.

BACKGROUND: Patients with heart failure (HF) in the community represent a large and growing patient population whose complex care requires implementation of innovative care modalities. The Centre Hospitalier--Centre de Sante et de Services Sociaux--Corridor of Service for Heart Failure Patients (CH-CSSS-CSHFP) represents a novel approach to address the challenges of delivering comprehensive care to HF patients in the community. PURPOSE: In this study, the researchers aimed to answer the question: What is the patient's perception of care received in the CH-CSSS-CSHFP? METHOD: A descriptive qualitative design and semistructured interviews guided the inquiry. SAMPLE: A convenience sample (n=5) of HF patients was recruited from five community health centres. RESULTS: Themes that arose from analysis included "Staying home": A shared goal of the patient and service, "Checking on": Health-related monitoring, and "Being connected": Ties to the health care system. CONCLUSION: Results of this study provide insight into the patient's unique perspective on how this service has impacted his/her HF management and may assist health care professionals in designing more effective community-based services.

Acceptability and feasibility of recruitment and data collection in a field study of hospital nurses' handoffs using mobile devices.

BACKGROUND: The portability and multiple functionalities of mobile devices make them well suited for collecting field data for naturalistic research, which is often beset with complexities in recruitment and logistics. This paper describes the implementation of a research protocol using mobile devices to study nurses' exchanges of patient information at change of shift. METHODS: Nurses from three medical and surgical units of an acute care teaching hospital in Montreal, Canada, were invited to participate. On 10 selected days, participants were asked to record their handoffs using mobile devices and to complete paper questionnaires regarding these exchanges. Nurse acceptance of mobile devices was assessed using a 30-item technology acceptance questionnaire and focus group interviews. The principal feasibility indicator was whether or not 80 complete handoffs could be collected on each unit. RESULTS: From October to December 2017, 63 of 108 eligible nurses completed the study. Results suggest that the use of mobile devices was acceptable to nurses, who felt that the devices were easy to use but did not improve their job performance. The principal feasibility criterion was met, with complete data collected for 176, 84, and 170 of the eligible handoffs on each unit (81% of eligible handoffs). The research protocol was acceptable to nurses, who felt the study's demands did not interfere with their clinical work. CONCLUSIONS: The research protocol involving mobile devices was feasible and acceptable to nurses. Nurses felt the research protocol, including the use of mobile devices, required minimal investment of time and effort. This suggests that their decision to participate in research involving mobile devices was based on their perception that the study protocol and the use of the device would not be demanding. Further work is needed to determine if studies involving more sophisticated and possibly more demanding technology would be equally feasible and acceptable to nurses.

Using reflective nursing practice to improve care of women with congenital heart disease considering pregnancy.

This article examines the issue of congenital heart disease (CHD) in women, specifically women who are considering pregnancy. Some of the authors' experiences with women with CHD are described, and a reflective approach to clinical practice is used to gain a greater understanding of the women's perspective. Women with CHD need to balance general lifespan developmental tasks with issues specific to their CHD, such as changes in functional abilities or the possibility of a shortened life expectancy. In women with CHD, physiological, psychological, and family issues need to be considered when they are contemplating pregnancy. As women with CHD move through this debate, nurses may play a key role in assisting them in their decision-making process by exploring issues related to pregnancy and CHD. This exercise in reflective nursing practice allowed us to review the literature, gain new knowledge from our patients, use that knowledge to help other patients, and thoughtfully consider what still needs to be discovered in the care of reproductive-aged women with CHD. The subject of pregnancy contemplation in women with CHD in requires systematic research.

Effect of the Postpartum Hospital Environment on the Attainment of Mothers' and Fathers' Goals.

OBJECTIVE: To describe mothers' and fathers' goals in the postpartum period and how the hospital environment enables or hinders the attainment of these goals. DESIGN: A qualitative descriptive design was used to explore participants' perceptions. SETTING: Mothers and fathers were recruited on the postpartum unit of an urban hospital. PARTICIPANTS: Ten mothers and eight fathers participated. METHODS: Semistructured interviews were conducted with mothers and fathers individually. Data analysis occurred concurrently with data collection and informed subsequent interviews. RESULTS: Mothers and fathers expressed similar goals: developing parenting competence and fulfilling personal needs. Their narratives indicated that the organizational environment with the mission to promote and provide baby-friendly and family-centered care and the human environment of responsive nursing were closely aligned with their goals. In contrast, the routines of the unit and the physical environment were not consistent with parents' goals or the mission of the organization. CONCLUSION: Nurses have important advocacy roles in ensuring that all dimensions of the postpartum environment support the ability of parents to attain their goals and align with the philosophy of care of the organization.