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The Effects of Verbal Handoff Communication between Health Care Personnel during Patient Transfer Care

Introduction

In healthcare facility settings, the transfer of essential information and the responsibility for care of the patents who are transferred from one setting to another is an integral part of communication. Such a critical transfer point (handoff) entails the acceptance of the patient care responsibility via effective communication, and includes the opportunity to ask questions, seek clarification and make confirmations in regard to the patient care. Some of the vital information that is shared via verbal handoff communication during patient transfer includes the patient’s complaints, the diagnosis by the initial practitioner, care given to the client so far, how the patient has been responding to the treatment so far, and the care that is still expected. In the United States healthcare facility settings, transitions occur severally and in multiple ways in any given day. Consequently, this study examines the effects of verbal handoff communication among health care personnel during patient transfer care in the healthcare settings.

Statement of the Problem

Information transfer between healthcare practitioners about their patients is increasingly getting a significant concern with regard to the improvement of patient care quality, patient safety and the workflow. Ineffective communication during the transfer of the patient can result in delays in medical diagnosis, wrong treatment, patient’s complaints, increased healthcare expenditure that the clients are not prepared for, delays in the disease diagnosis, the risk of adverse effects and other side effects that impact on the care system (Bowman, 2010). While the Joint Commission requires accredited healthcare institutions to use standardized approaches to verbal handoff communication, about 80 per cent of the medical errors occur due to miscommunications that happen during the patient transfers.

Background of the Problem

Given the effects of poor and ineffective communication during patient transfers, the state of Iowa through the Joint Commission has recognized patient safety as a priority. According to Bowman (2010), The Joint Commission teamed with the US healthcare system and some hospitals through the Center for Transforming Healthcare to seek ways of reducing errors that result from poor healthcare practitioner communication during patient transfer. Systems such as SHARE and TeamSTEPPS are among the few systems and processes that are identified to help in reducing patient risks.

Literature

Understanding Handoff Communication in Nursing

Handoff communication is the term used to refer to exchange of information about a patient’s summarized situation with the aim of influencing further decision making and subsequent patient’s care positively (Hinami, Farhan, Meltzer, & Arora, 2009). The responsibility of a patient is transferred from one medical personnel to another, normally from one department to another department of the same medical institution. Sometimes, handoff may be used to refer to other near-synonyms including report and sign out communication. While handoff definition emphasizes more on the information exchange, it entails more activities than information exchange. There are several changes that occur during handoff that may include important changes in control and/or responsibility. By omitting the significant changes other than information exchange, ‘handoff’ would signify only the various sorts of exchange of information about the patient (Mascioli, Laskowski-Jones, Urban, & Moran, 2009).

Various reviewers have made suggestions about the control concept to be covered by handoff communication. A number of collaborating health systems and hospitals began a project to effect the communication of practitioners during the handover of patients; they defined handoff communication as the most effective way of handing over patient’s responsibility and acceptance of responsibility by the receiving party. They further went ahead to conclude that it is a real-time process whereby specific information about a patient is transferred from a personnel or a team of personnel to another personnel or another team of medical personnel to make sure that the patient’s care and safety is continuous (Ong & Coiera, 2011). The entire process of handoff involves three parties of people: the “senders”, employees who conduct transition care and transmission of the patient’s information and finally, the “receivers” who receive the information and assume responsibility and care of the patient.

Handoff information is not only the information transfer about a patient from a particular team of caregivers to another team. It may also involve the transfer of patient’s information from the caregiver(s) to the family of the patient or even the transfer of information from a given type of health-care institution to a different health-care institution or from a health-care institution to the home of the patient. All these are meant to achieve one major goal, which is ensuring safety and continuity of the patient’s care (Hinami et al. 2009). The information being exchanged is critical as it defines the condition of the patient and the expected changes thereby intended to influence the decision making of the subsequent caregivers. The information being transferred normally includes patient’s recent condition change, possible changes, his/her current condition, and the ongoing patient’s treatments (Mascioli et al., 2009).

There are various situations where handoff communication is required in the medical field. The setting, through which handoff is necessary, inludes sign-out of a physician to a physician covering, nursing report about transfer of patient from a facility or unit to another facility/unit, communication between emergency department and the staff at the receiving facility during transfer, transfer from primary care to admission, change of shift of nursing reporting, anesthesiology reports transfer to staff at the post-anesthesiology recovery unit, and patients discharge to another facility or back home (Hinami et al., 2009).

Problems Associated with Handoff Communication Today

As a patient undergoes care, he/she may be attended to by different health-care specialists and practitioners in various settings, which constitute specialized outpatient care, surgical care, rehabilitation, primary care, emergency care, and intensive care (Ong et al., 2011). Furthermore, patients are expected to move between treatment, care and diagnosis areas severally and it is possible that three staff shifts may attend the patient daily making safety risk introduction at every interval to the patient. Handoff communication amongst or between the teams of care and between units may lack some of the information that is essential, or still the misinterpretation of information may occur (Hinami et al., 2009). The communication gaps that occur due to such shifts may result in severe effects to the care continuity of the patient, possible harm on the patient, and inappropriate treatment.

According to reports from the United States of America Joint Commission, communication breakdown was the major root cause of events of sentinel until 2006 from the mid 1990s. Furthermore, it was the single most occurring major cause resulting in claims that emerge from transfer of patients in a malpractice insurance agency in the USA (Ong et al., 2011). Of the tens of thousands of factors leading to permanent disabilities that could be prevented in Australia, communication issues accounted for over ten percent, which is contrary to less than ten percent resulting from insufficient skills among the practitioners. The above findings show that the communication issue is a big problem that should be given more attention currently (Mascioli et al., 2009).

The handoff communication is an issue of global concern: the United Kingdom of Great Britain and North Ireland and Australia are the most recent cases to review the communication problem in handoff and make recommendations to reduce the risks, and most of them are currently being studied. Unambiguous, face-to-face, precise communication was concluded to be the most effective communication during handoff according to a study (Ong et al., 2011). On the other hand, the experts in the patient safety field have argued that care delivery system redesign should be involved in finding the developing solutions, which is the most likely way of resolving the issue of handoff communication (Hinami et al., 2009). They claim that system design improvement should be done in such a way that the caregivers will be made to understand how mistakes are made by humans, create forcing functions, developing redundancies in the care processes, and process step reduction thereby minimizing the chances of making errors (Henriksen, Battles, Keyes, Grady, Mistry, Jaggers, & Meliones, 2008).

Partly, the handoff problems are developed from the way, in which providers of care are not or less educated (in communication skills and team training), system of health care that rewards and promotes individual performance and autonomy, and scarcity of well trained and experienced role models. The medical culture that has historically failed to put significant emphasis on families and patient’s involvement in the caregiving has been found to be a root cause, as well (Ong et al., 2011). In addition to this, despite the fact that health care practitioners specialization can result in healthcare improvement, it also results in more people getting involved in the care giving of the patient, which can possibly make communication even more complicated (Mascioli et al., 2009). The scenario where the caregivers’ demographics do not concur with that of the community being attended to, as well as relying much on foreign health-care practitioners are two other causes of handoff communication problems (Henriksen et al., 2008).

Effect of Handoff Communication

According to the above definitions of handoff, communication is the exchange of information as the medical personnel enter and exit the patient’s care responsibility. From the definitions, it is evident that the primary aim was to ensure safety and care continuity of the patient. However, the purpose of handoff is to perform a function of a wider scope. Various other numerous and important functions are accomplished during the handoff process; these functions are in addition to care and safety quality continuity (Freitag & Carroll, 2011). The two major functions are to signify or ensure that control and responsibility is effectively transferred. The amount of information being transferred does not matter as long as the person responsible is different from the earlier one, which means that the decisions made on the patient’s behalf have been left to another person. Ill-defined patient responsibility results in, at least, waste of time in searching, and usually, severe consequences on the side of the patient (Apker, Mallak, Applegate, Gibson, Ham, Johnson, & Street, 2010).

The ‘sign-out’ term is at times used to refer to the change in situation and making strong implications that responsibility - in most cases, covering legal responsibilities - is now in the hands of other nurses or physicians (Freitag et al., 2011). In the same way, handoffs happen and patients control is transferred, for instance, when a patient transferred from an Emergency uunit to a different unit such as Pediatrics or Cardiology. Responsibility and control are not always transferred independently; they are transferred concurrently as the transfer takes place, and it does not imply the same things. The disconnection is often seen when an inpatient physician “does not have the freedom to frequently attend to a patient” yet the physician has already assumed patients’ responsibility from the ED (Sullivan, 2007).

Taking into consideration that handoff is handing over information, control and responsibility of an individual patient, it should not be overlooked that in reality, responsibility for transfer is normally applicable to a group of patients (Apker et al., 2010). Usually, in such conditions, an extra dimension is included that is referred to as the portfolio problem defining which one among the various groups of patients requires most attention than the rest at handoff. Upon the handoff completion, it should be defined, which one among the group should be granted response of the highest priority or most care. Having answers to these questions is very important in the proper management of issues that might emerge; however, it is not the information in regard to an individual patient but information about the entire group (Freitag et al., 2011).

To summarize, functions in handoff beyond the responsibility and control transfer can be divided in four sections. The first of the four functions is the effective transmission of information about the patients; this has been a most significant focal point in the recent past. The rest come from other sections that occur simultaneously: first is the correction of errors that may occur during caregiving; the second one is individual learning while the third and last is the organization learning (Hinami et al., 2009). 

Correction of errors implies the conversation between the receiving and the handing over personnel allows asking and answering questions that can be criticized, which results in correction in deeper levels. Individual learning is referred to the information exchange process, which leads to learning in the sense that the caregiver’s assumptions and skills are altered thereby conditioning his/her actions in regard to the current patient and future patients. Organization learning-information exchange at handoff may undermine, spread, or reinforce informal norms thereby altering ways of obligation and duty perception by the group. Furthermore, due to the wide diffusion of opinion and knowledge such that it arguably becomes the believed or widely known concept among the staff members (Freitag et al., 2011).

Ways of Improving Handoff Communication

The handoff communication efficiency can be enhanced effectively by making it standardized for particular patients (Ardoin & Broussard, 2011). According to Nemeth et al., the above method of improving handoff is true based on the discussion provided above. The handoff process for new patients is more involving and extensive while handoff for continuing patients is a very brief discussion. When standardization is achieved, there will be negligible variation in the context of the institution, but the care variation occurs between patients handling (Nemeth, Kowalsky, Brandwijk, O’Connor, Nunnally, & Klock, 2005). However, the standardization is not only a function of duration; such factors as severity of the condition, family circumstance, comorbidities, and other factors are considered to have a notable effect on the decision of treatment and, therefore, should not be omitted in the information being transferred.

It is important to note that while it is arguably correct that standardizing patients handoff will reduce probable errors and omissions in the communicated content when time is a limiting factor, the protection of the patient against omission and errors is reduced to a notable degree to enable allocation of sufficient time for distinctive aspects for individual patients and the variation in the cumulative workload, as well (Apker et al., 2010). According to the World Health Organization, the standardized approach to handoff communication among medical personnel, as well as among various patients, units of care and shifts change in the patient transfer course should be implemented (WHO, 2006).

The WHO goes further to give the implementation guidelines, which include making use of the Situation, Background, Assessment, and Recommendation (SBAR) technique (Haiq, Sutton, & Whittington, 2006); setting aside enough time for the handoff communication of critical information and also for the response and asking of questions by the staff, with as minimum disturbances as possible (inclusion of read-back and repeat-back steps in the handoff process) (Nemeth et al., 2005); all the information concerning the patient’s medication advance directives, status, treatment plans and any notable changes in status should be provided during the handoff communication process, and the information exchange should only be based on the content that is only necessary to affect provision of safety and care continuity to the patient (WHO, 2006).

The health-care organizations are required to activate discharge systems, in which the subsequent healthcare facility and the patient him/herself are provided with all the important information in regard to treatment plans, test results, discharge diagnoses and medications. Another approach is that effective handoff communication systems should be included in training for the development of continuing professional in the case of health-care professionals, as well as in education curricula. The last approach is to make communication between medical institutions effective by offering parallel care for same patients to be professional (Ardoin et al., 2011).

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