This thesis is a phenomenology study about the experiences of the nurses related to handoff communication. This thesis is divided in to five chapters. This chapter comprises of four sections. Section one provides the background of the study topic. Section two presents the study purpose. Section three lists the study question. Section four elaborates on the significance of the study to nursing.
Background of the Study Problem
The process of transferring pertinent patient information from one caregiver to another is called handoff (Shaw, 2009). In the literature, different words are used as synonyms of handoff and those are patient care handover, transfer of accountability, bedside reporting, and shift handover (Alvarado et al., 2006). Throughout this thesis, the word handoff will be used to refer to the process of handoff which can take place between two individuals, or between group of people with an aim to maintain the continuity of patient care (Riesenberg, Leitzsch, & Little, 2009). Moreover, handoff can take place between different health care providers that includes nurses, doctors and other paramedics. Current thesis focuses on the handoff that occurs between nurses. Despite considerable institutional and technological changes, handoff has maintained its significance in nursing practice (Manias & Street, 2000) and is repeated three times each day in every in-patient unit (Riesenberg et al., 2009). Handoff serves a vital function of transferring patient care responsibility and accountability from off-going nurse to upcoming nurse (Strople, & Ottani, 2006). Furthermore, handoff process follows three steps that includes content transfer (all patient related information), clarification and inquiry (asking and answering the questions), and the historical view (reviewing charts and files) (Welsh, Flanagan, & Ebright, 2010).
Nurses use various methods to communicate during patient care handoffs. Traditionally, handoff occurs face-to-face in an office or conference room (Anderson & Mangino, 2006). Beside this, the second most common form of report is taped shift report where nurses record their verbal communication of the handoff on a tape recorder for the oncoming nurse to listen to and review as needed (Anderson & Mangino, 2006). Third type of handoff occurs among caregivers of different department, such as emergency department staff handoffs the patient to the intensive care unit staff. This type of handoff is commonly delivered via telephone communication or via written report. Research reports that face-to-face handoff is the ideal mode of communication that provides opportunity to ask questions (Alvarado et al., 2006; Anderson & Mangino, 2006; Patterson, Roth, Woods, Chow, & Orlando, 2004). Though, handoff has explicit function of transferring patient care responsibilities among nurses, it has some other functions too. Qualitative study by Hopkinson (2002) revealed that nursing handoff provides a forum where nurses can discuss their opinion and express their feelings.
Amato-Vealey, Barba, and Vealey (2008) argue that communication is the fundamental component of handoff process and that the communication during handoff must be accurate, clear, and specific. Furthermore, it is believed that handoff serves as a vulnerable point in patient care where insufficient and inefficient care transition can result in avoidable harms and medical errors (Cosby et al., 2008; Streitenberger, Breen-Reid, & Harris, 2006; Strople & Ottani, 2006). According to Adamski (2007) Institute of Medicine estimated that around 44, 000 to 98, 000 hospital patients die annually because of injuries in the care due to errors. Besides this, The Joint Commission on Accreditation of Healthcare Organization (JCAHO) claimed that issues of communication, continuity of care or care planning were the root causes in more than 80% of the reported sentinel events (Streitenberger et al., 2006). Furthermore, retrospective study by Cosby et al. (2008) explored causes of morbidity and mortality in last fifteen years in an emergency department (ED) and revealed that 61% of the patient care management problems were related to lapse in the communication between the health care team members. Furthermore, with an aim to uncover the patterns of communication breakdown in surgical department, Greenberg et al. (2007) concluded that 43% of the communication breakdown occurred at the time of handoff and resulted in the injury to the surgical patients. The literature suggests that lapse in communication during handoff is the most common cause of error. Moreover, it also indicates the inadequacy of the communication method that is utilized by the health care providers during handoff (Hohenhaus, Powell, & Hohenhaus, 2006).
One of the challenges that nurses face during the handoff is absence of a standardized tool to facilitate nurses’ handoff process (Arora & Johnson, 2006). The basic reason for the lack of standardized tool is the variability in the patient care need and the clinical areas’ requirement. Keeping in mind the importance of this issue, quality improvement initiatives by World Health Organization (WHO) and JCAHO mandates the standardization of the handoff process as a key to prevent the adverse events in the clinical care (Pesanka et al., 2008). For this very reason, many recent studies have reported implementation of tools in different clinical setting like in preoperative care (Amato-Vealey et al., 2008), surgical care (Sandlin, 2007), and in emergency room (ER) (Clancy, 2006). In general, kardex is the most common nursing handoff tool that is used in most of the hospitals worldwide (Crabtree et al., 2009). Importantly, kardex provides structural guide to share patient information during handoff but does not provide a particular sequence for the information sharing. For this reason, it is observed that nurses share handoff information in different sequence and this may result in the omission of important information during handoff. Moreover, it is also observed that the kardex are not always utilized appropriately by nurses and neither are they reviewed or updated in timely manner. In addition, incomplete documentation on the kardex is also reported (Crabtree et al., 2009).
During the three years of work experience, nursing handoff practices at Aga Khan University Hospital (AKUH) were observed and exercised by the researcher. Following paragraph briefly describes the handoff practices at AKUH. Each in-patient unit has nursing handoff as the key ritual that is repeated by nurses at the end of the shift. During handoff process, of going nurse handoff the patients care responsibility to upcoming nurse. The handoff between nurses is usually face-to-face and kardex or patient bedside files or red files are utilized to organize and present the pertinent patient information during handoff. During handoff, upcoming nurses take notes about the patient information so that they can refer to this information during their shift. In the morning and evening shifts, nursing handoff takes place at the bedside of the patient whereas, at night shift, handoff process is carried out at the nursing station.
In addition, to the variability in the handoff process due to lack of standardized tool, there are some other factors that can affect the handoff process. These can either facilitate or hinder the handoff process. It is important to note that the environmental disturbances may also distract the nursing staff during the handoff process (Kosits & Jones, In press; Montgomery, 2007). And because this disturbance creates a cognitive shift, this may lead to the slip of necessary information (Montgomery, 2007). In addition, qualitative study by Welsh et al. (2010) explored the nurses’ perception of the barriers and facilitators of nursing handoff. Twenty nurses were interviewed to explore their perception on the effectiveness of two different type of handoff format (face-to-face handoff, and audiotape handoff). Inconsistent format, inadequate information and limited opportunity to ask questions were the main themes under the limitations of the nursing handoff. Facilitators were the face to face interaction and the consistent checklist/form.
Furthermore, Solet, Norvell, Rutan, and Frankel (2005) argue that lack of formal attention or education to reinforce handoff process is another challenge that faces nursing. Astonishingly, Eaton (2010) claims that the handoff process is learnt by modeling the senior staff that is equally untrained for the same. Thus, it is clear that nurses learn this key nursing ritual by observing their colleagues on the unit and it can be assumed that they assimilate the learnt process differently. It is claimed that nurses’ understanding of the handoff process guides them to use different patterns of communication and language to interact with each other (Manias & Street, 2000). Moreover, it is believed that nurses share the handoff information depending on their values and interest (Manias & Street, 2000). These values can be personal or the contextual. For instance, the surgical nurse may be more concerned regarding handing over the information related to pain at the surgical site, assessment of pain, and pain medication. Hence, the handoff process is greatly influenced by the nurse’s own values, interests and experiences. And if the handoff process is to be understood in its true sense, nurses’ experience related to handoff seems essential to be explored. For this reason, the current study aims to explore the nurses’ experiences of handoff communication.
Purpose of the Study
The purpose of the current study is to explore the experiences of medical surgical nurses related to the handoff communication and also to explore nurses’ experiences of the barrier and the facilitators of the handoff communication.
Study Question
The current study has two main questions that are stated below.
What are the nurses’ experiences of the handoff communication?
What are the nurses’ experiences of the facilitators and barriers to the handoff communication?
Significance of the Proposed Study to Nursing
As stated in the background section, handoff process allows transfer of patient care related information from one nurse to another. This key process is repeated by nurses three times each day, in each in-patient unit. Omission of pertinent information during handoff can result in avoidable harm and medical errors that can significantly affect the patient health outcome. Despite its significance, handoff process is not reinforcement during formal nursing training and nurses learn this process by role modeling their seniors and perform it accordingly. In addition, it is claimed that handoff process is learnt and assimilated differently by nurses. Besides this, handoff process is influenced by nurse’s own value, interest and experience. Therefore, it is important to explore nurses’ experiences related to handoff communication and current study aims to explore the same.
The current study will be the first study on the nursing handoff in Pakistan. This study will explore the nurses’ experiences of the handoff communication and indentify the barriers and facilitators of handoff communication. This study will allow nursing leaders and advance practice nurses to develop an understanding of the handoff process as experienced by the nurses. This study will indicate the specific areas in the handoff process that can be targeted to implement improvement strategies. The finding of the study may point out system related problems and thus will help bring the change at the system level. This study will help improve nursing practice that will result in decreased medical errors and enhanced quality of patient care (Odom-Forren, 2007).
Chapter Three
Methodology
Methodology chapter has been divided in to seven sections. First section describes the study design. The second section focuses on the study population and setting. Third section explains the sample and the sample size for the current study . Section five explains the sampling technique and section sixth presents the process of field entry. Seventh section addresses data collection sources. Section eight elaborates on the data analysis plan followed by the section nine that discusses ethical consideration. Limitations are explained in the tenth section. This chapter ends with the summary.
Study Design
The current study will explore the experience of the nurse related to the handoff process. The study question can be answered by using the qualitative approach (Polit & Beck, 2008). As the purpose of the study is to explore the experiences of nurses, the phenomenological approach is the most appropriate qualitative study design (Polit & Beck, 2008). According to Van Manen (1990) the phenomenology research allows description of the experiential meaning of the phenomenon as experienced by the subject. For this reason, researcher will use phenomenological study design to explore the nurses’ experiences of handoff process. Phenomenology research can be descriptive or interpretative (Polit & Beck, 2008). It is important to mention that the current study aims at describing the experiences of nurses related to handoff, so descriptive phenomenology will be used in this study (Van Manen, 1990).
Study Population and Setting
The study population would be the nurses working in the general ward of the medical surgical unit at The Aga Khan Hospital. The reason for selecting the nurses who are working in the ward area is that each nurse who works in the ward is assigned to10-15 patients. In the researcher’s experience, the nurse patient ration in the ward is the highest when compared to the ICU where one nurse is assigned to 1-2 patients or in special care units, where nurses are assigned to 4-5 patients. So, researcher opts to understand the experience of the nurses who work in the words of medical surgical units and who receive handoff of 10-15 patients in the given time. In addition, during literature review it was found that many studies on handoff are conducted in ER, preoperative care, intensive care unit (ICU) and surgical units. So, on the basis of available knowledge, researcher decided to conduct the study in the ward setting. In qualitative approach, researcher utilizes “ naturalistic setting” with an aim to study the phenomenon in the real world (Polit & Beck, 2008, p. 57). And as researcher wants to explore the nurses’ experiences related to handoff, hospital will be the setting where the researcher will actually conduct a study. And the AKUH will be the setting for the current study that will include C1 ward, and B1 ward that are surgical Unit and C2 ward that is the medical unit.
Sample
According to Polit, Beck and Hungler (2001) there is no well defined criteria for sample size in qualitative research. However, adequacy and appropriateness are two factors that determine the scope of sample in a qualitative study (Polit, Beck & Hungler, 2001). Adequacy refers to the sufficiency and quality of the data that the researcher obtains, whereas, appropriateness refers to the method that researcher uses for the sample selection (Polit, Beck & Hungler, 2001). To ensure adequacy of the data, researcher will continue the inquiry until researcher will have sufficient data in each category. For ensuring appropriateness, researcher will purposefully recruit participants to the study who have experience of the phenomenon under study. Beside this, researcher will include participants who may contribute different experiences to the study. In qualitative study, data saturation is another principle that is used by the researcher while collecting the data (Polit & Beck, 2008). Data saturation occurs when themes and categories in the data become repetitive and no new information is obtained by the researcher (Polit & Beck, 2008). According to Polit, Beck and Hungle (2001) phenomenological studies have sample size of 10 or less. Thus, the researcher will recruit 10-13 participants in the study and will stop inquiry when saturation would be reached.
Sampling
The purposive sampling strategy will be used to enroll informants in this study. In this type of sampling, researcher purposefully select the participants who have a lived experience of the phenomenon under study (Polit & Beck, 2008). It is argued that in qualitative inquiry, purposive sampling becomes the strength of the study (Polit & Beck, 2008). Purposive sampling becomes the strength because it allows conceptual understanding of the phenomenon (Polit & Beck, 2008). In the current study, participants with the following characteristics will be recruited. The nurses who are working at bedside in the general ward of medical surgical unit, who have at least two years experience of bedside nursing in general ward, who are willing and available to participate in the study, and who can speak Urdu or English. The nurses with two years experience will be recruited on the bases of Dreyfus brothers’ model of skill acquisition (Benner, 1984)
Unlike the quantitative inquiry, where representativeness of the sample is a major concern, in qualitative inquiry, the researcher is more concern regarding the richness of the data (Polit & Beck, 2008). According to Patton (2002, cited in Polit & Beck, 2008) researcher can employ different strategies within purposive sampling that help researcher to get the rich data. Maximum variation is one of those strategies (Polit & Beck, 2008). Researcher will utilize this strategy during study to recruitment the participants. This strategy allows recruitment of the participants who are from diverse background who may contribute the different viewpoints and experiences about the phenomenon to the study (Polit & Beck, 2008). So, research will select the participant based on the variation in their age, gender, years of experience, graduating school and professional degree.
Gaining Access to the Field Site
According to Polit and Beck (2008) getting entry in the field requires researcher to negotiate with the ” ‘ gate keepers’ who have authority to permit the entry in their world” (p. 70). To get entry in to the field site and access the potential participants, researcher will formally meet the director nursing services, medical surgical unit nurse manager and head nurses of C1, B1, and C2 ward. During the meeting, researcher will convey the information of the study with the help of a brief power point presentation. This presentation will cover all important information related to the study and permission will be sought from all the leaders for initiating the study. After getting the formal approval from the ethics committee, researcher will request nurse manager and head nurses to inform the medical surgical nurses of an opportunity to participate in the research. After obtaining the permission for the head nurses of C1, B1, and C2 units, an advertisement will be placed at each unit at the clean utility, and nursing lounge. The advertisement will contain information regarding the study and the researcher’s contact number.
The participant who will call the researcher and show the willingness to participate in the study, they will be provided with demographic form to fill (please refer appendix A). Demographic forms will include information related to age, gender, highest professional degree, unit name, years of experience, AKUSON graduate or non AKUSON graduates and current position. The researcher will collect all the forms from three units and carefully see the participants’ characteristics like age, gender, nursing degree (RN or BScN), AKUSON graduate or non AKUSON graduates. Participants with varied characteristics will be recruited in the study to better understand the phenomenon of handoff. Researcher will inform the selected nurses that they have been recruited as study participants.
Data Collection
In current study, researcher will opts to start data collection between the month of February 2011 to April 2011(please refer appendix B for the timeline). The main data source that is used by the researcher in phenomenological study is the in-depth conversational interview (Van Manen, 1990). During interview, researcher allows person to describe the phenomena in much detail and refrains from leading the discussion (Van Manen, 1990). The proposed study will utilize face to face, in-depth conversational interviews to explore nurses’ experiences related to the handoff communication. Once the consent would be provided by the participant, the interview time and the venue will be mutually agreed upon by the researcher and the participant. It is suggested that distractions and interruptions during the interview should be controlled (Polit & Beck, 2008), therefore the researcher will reserve the interview venue which allows uninterrupted and undistracted conversation. Possible venue would be the conference room in the C1, B1, and C2 wards that will be utilized for interview.
Interview will be conducted with each participant separately. The duration of interview will be 50-90 min. The interview with the participants will be scheduled on their day off or just before starting of their duty. Participants will be asked the following question to respond “ Tell me about your experiences related to the handoff communication? Researcher will use probes during interview to get the detail description of the phenomenon. Researcher will record the interview on the ICD recorder after seeking the permission from the participants. According to Polit and Beck (2008) in some instance, tape recorder fails or improperly records the interview for this very reason, researcher will take notes during the interview so that if ICD recorder fails to record in any case, researcher can refer the interview notes. Just after completing the interview, data will be transferred from the recorder to the computer.
Data Analysis Plan
In qualitative study, data analysis is an ongoing process that starts at the data collection phase (Polit & Beck, 2008). For this reason, the researcher will start data analysis simultaneously with the data collection phase. According to Polit and Beck (2008) descriptive phenomenology follows four basic steps that includes bracketing, intuiting, analyzing and describing.
Step one includes bracketing, where the researcher will write all the preconceived experiences and ideas on the piece of paper. In this way researcher will becomes aware of own perception and experiences (Creswell, 1998). It is suggested that the phenomenological researcher maintains the “ reflective journal” and reflect on the self on the regular bases to ensure ongoing bracketing (Polit & Beck, 2008, p. 228). Keeping in mind the importance of ongoing bracketing, the researcher will maintain the reflective journal and will write down her experience before starting the data collection as well as will document her feeling throughout the study period. In intuiting phase, the researcher will openly accept the meaning that is attributed to the phenomenon by the participants. In analysis phase, researcher will use data analysis approach put forward Van Manen (1990).
For the current study, data will be transcribed by the transcriber. The person who has a good command on Urdu and English language, will be hired for the transcribing the data. During first step of data analysis, researcher will read the transcription several times to obtain the meaning from them. In this step, researcher will read the transcriptions and understand the meaning of the phenomenon from the participants’ viewpoint (Van Manen, 1990). In second step researcher seeks meaning of the phenomenon by identifying “ thematic” from the various experiential accounts (Van Manen, 1990, p. 87). According toVan Manen (1990) “ Theme is the process of insightful invention, discovery and disclosure”(p. 89). Then each transcription will be reviewed by the researcher to extract the pertinent statement from it (VanManen, 1990). Researcher will select the statement from the accounts that best compliments the theme. In the next step, researcher will organize and develop the clusters of the themes (Van Manen, 1990). Later, researcher will formulate the description of the studied phenomenon. In this step researcher will develop textual description (What happened) and structural description (how the phenomena was experienced) (Van Manen, 1990). Beside this, in this stage, researcher “ develops thematic description from the artistic source by certain narrative that explicates the theme while remaining true to the universal essence of the experience” (Van Manen, 1990, p. 97). This will allow the researcher to develop the overall description of the experience, the essence. After this, researcher will integrate results with the descriptions of the phenomenon that is under study (Van Manen, 1990).
Ethical Consideration
The ethical principles that need to be considered in the current study are the beneficence, respect for the human dignity and justice (Polit & Beck, 2008). In the current study, participants are likely to share the information related to the errors, incidences or experiences that are related to their professional life. In such a case, principle of beneficence that includes the right to protect from the exploitation needs important attention of the researcher (Polit & Beck, 2008). The right to protect from the exploitation requires the researcher to mention to the participants that the information that comes to researcher’s knowledge during the interview will not be used against the participants (Polit & Beck, 2008). Therefore, in current study, researcher will clearly inform the participants that the information that is shared with the researcher will not be used against them.
Another important principle that needs attention in the current study is the principle of human dignity. The principle of human dignity includes the right to self-determination, and the right to full disclosure (Polit & Beck, 2008). To ensure the right to self-determination, researcher will explain the participants that participation in the study is their voluntary decision and they can decide to leave the study at any time (Polit & Beck, 2008). Researcher will follow the principle of right to full disclosure and will include all the information related to the study in the consent form. At the first contact, consent form will be provided to the participants (please refer appendix C) and researcher will allow them time to go through the form line by line and ask question.
In qualitative inquiry, principle of justice becomes a significant principle to be considered because, researcher spends much time with the participant and come to know about the participant’s belief, value, background, culture, habits etc (Polit & Beck, 2008). In such a case, researcher is required to demonstrate the respect for each participant and be nonjudgmental (Polit & Beck, 2008). Moreover, researcher is required not to invade in participant’s personal life unnecessarily (Polit & Beck, 2008). Therefore, in the current study, researcher will make every effort to honor every participant for what they are as a human and will refrain from invading in to the participant’s personal life. Researcher will explain the participants that anonymity and confidentiality will be maintained throughout the study. To ensure the anonymity researcher will create and consistently use a system of pseudonyms or codes. Beside this, the key that links the participants’ names with the code will be kept in the locked cabinet.
Study Rigor
Regardless of what research methodology is employed by the researcher, study rigor holds the significance for it makes the research credible. In qualitative inquiry, rigor (trustworthiness) has four criteria (Lincoln & Guba, 1998). This includes credibility, transferability, dependability and confirmability (Lincoln & Guba, 1998). During the study, researcher will follow certain steps to ensure the rigor of the study is maintained. To maintain credibility of the research, the researcher will use member check strategy. Researcher will involve thesis supervisor at each step of the data analysis. Moreover, another strategy that the researcher will employ is bracketing. As explained in the data analysis section that the researcher will maintain the reflective journal to prevent subjectivity and bias in the data collection and interpretation.
According to Lincoln and Guba, (1998)” transferability is always relative and totally depends the degree to which the salient conditions overlap or match” (p. 241). It is suggested that in qualitative research, transferability of the findings can be ensured to some extent if researcher provides detail description of the time, context and the culture in which the study was carried out (Lincoln & Guba, 1998). Therefore, researcher will record details of the setting in terms of its culture, function and the structure and will also document participant’s characteristics. Confirmability refers to the “ concern of the researcher to assure that the data interpretation and outcomes are rooted in the context and person a part from evaluators and are not simply figments of the evaluator’s imagination”(Lincoln & Guba, 1998 p. 243). To maintain the confirmability, researcher will go through the data again and again. Moreover, researcher will involve supervisor at each step of data analysis to make sure that the phenomenon is described and interpreted as experienced by the participants. Beside this, researcher will verify the transcription with the audiotapes to check for the errors or loss of any information by mistake.
Limitation of the Study
Limitations that researcher foresee for the current study are stated in the bellow paragraph. As a student, completing this study within one year is the requirement of the MScN degree program, for this reason, the major limitation is the time constrains. Another limitation is related to the qualitative inquiry, that is, the transferability of this study finding is limited to the area that is the medical surgical unit at AKUH. Third limitation that researcher predicts is that during translation of the data from Urdu to English, valuable data or its meaning can be lost. So, researcher will try to preserve the conceptual meaning of the narrative and in case where there will be the dengue of losing the meaning of the word, words will be kept transliterate (Creswell, 1998).
Summary Of methodology chapter
To summarize, in the current study, descriptive Phenomenological study design will be used to explore the experiences’ of nurses related to handoff. The setting will be the AKUH and the population would e the nurses working in the general ward of medical surgical unit. Gate keepers will be contacted before applying for the ERC approval. Once the permission for the study is provided by the director nursing services, ERC form will be send for the ethical review of the research. Participants will be recruited in the study by purposive sampling. In qualitative research, this type of sampling is often used with an aim to contact those individuals who can give rich information about the phenomena under study. Conversational interview of 50-90 minutes will be used as a data source. Participants’ will be recruited on the basis of the defined characteristics as detailed in the sample section.
Budget
For the budget of the current study, please refer appendix C.
