Patient, family and nurse experiences with patient presence during hand-off reports within hospitals: A systematic review.

Abstract

Review question/objective The overall objective of this systematic review is to synthesise the best available evidence on the experiences, beliefs, opinions, and desires of patients, families and nurses with regard to patient presence during hand-off reports. In meeting this objective, this review will consider the following review questions: 1.What are the expressed experiences of patients, families and nurses about patient presence during hand-off reports? 2.What do patients, families, and nurses believe are the advantages and disadvantages of patient presence during hand-off reports? 3.What are the circumstances that influence (prevent or allow) patient and family involvement in hand-off reports? 4.How much involvement in hand-off report do patients and families desire? Background The importance of hand-off reports in the delivery of patient care is reflected by the attention they are given within the literature, increasingly so in recent years. The World Health Organization (WHO)1 tells us that “underestimated is the handing over of patient information from an outgoing provider to an incoming one” (p. 66). In addition, a 2005 survey by the Joint Commission2 found almost 70% of sentinel events were the result of communication errors, including those that occur during hand-off reports. The heightened interest in exploring hand-off report processes may be due, in part, to changing workflow practices within health care environments3, furthering awareness of the role of communication in promoting patient safety4, and the need to ensure efficient use of limited health care resources5. Although many researchers identify hand-off reports as a necessary practice6, 7, 8, an alarming and consistent finding is that current approaches to hand-off reports may not be an efficient use of nurses' time and may actually compromise patient safety9, 10, 11. Nurses working in hospitals typically begin their shifts with a hand-off report, an activity that can occur up to four times in a 24 hour period. The purpose of hand-off reports is to share pertinent information about patients on a particular hospital unit. The data shared generally include information about diagnosis, age, patients' current condition, other health care professionals involved in the care, and any new or pending procedures12, 3, 10. The process for hand-off reports varies within and between institutions and nursing groups. Some of the more typical methods consist of taped-recorded reports, written reports, and face-to face communications between nurses and other health care professionals; all of which regularly occur at the time of shift change, specifically between health care professionals finishing their shift and those just starting. In recent years, various forms of technology have been used to facilitate hand-off reports13 and although such tools may be helpful they add another dimension to an already complex and controversial process. Irrespective of the method used to perform hand-off reports, it is questionable if the input of patients and families is considered during information exchanges. Research over the last 40 years shows that hand-off reports may actually threaten patient safety. Richard 14 noted a number of significant problems with the sharing of information during nurse hand-off reports. These include the omission of essential information and the sharing of information incongruent with patients' actual conditions. Safety is compromised when critical pieces of data pertaining to patients' care are not sufficiently transferred from one provider to another15, 16, 17, 18, 19, 14, 8, 20. Safety is also compromised when too much time is spent away from patients in order to convey information that could be deemed irrelevant or unnecessary to share during a report. Needleman and colleagues5 report hand-off reports consume up to 15% of nurses' work while Ekamn 21 found 38% of nurses' time is spent on the exchange of information. These errors can be potentially fatal and are linked to the reliance on the practitioners' recall16, 18, 19. Time spent in hand-off reports is costly, and takes valuable time away from providing direct patient care 22. As much as 93.5% of information shared during hand-off reports is readily accessible within patients' health records, care plans, or other data sources23, 13, 24, 22, 25, 26. Considering the demands placed on practitioners' time, these findings raise questions about the value of lengthy hand-off reports. More importantly, the question of how to maximise value within hand-off processes remains unanswered. A systematic review by Cohen and Hilligoss27 concludes that although hand-off reports in hospitals are highly complex and time consuming, they are essential in the delivery of safe and efficient patient care. In general, controversy about the approach to hand-off reports is significant and ongoing3. A recent systematic review by Poletick and Holly10 also questions the quality of information exchange between nurses, finding several problematic practices within hand-off report processes. According to Poletick and Holly10, nurses' communicative behaviours are not grounded upon best practice guidelines but rather a reliance on the familiar or ritualistic/habitual norms. While acknowledging the lack of a consistent approach and the multiple modes of communications (verbal, written, electronic) used during hand-offs in acute care hospitals, identifying the most appropriate and safest approach to hand-offs was beyond the scope of this review. Given that Poletick and Holly call for a consistent format and approach to hand-offs, there is a need to build on their work by examining the research on specific hand-off report approaches, and the inclusion of patients and families in the process. Both WHO1 and the Joint Commission28 concur, with the former calling for greater patient involvement in their own health care and the latter urging both patients and families to participate actively in information exchanges amongst practitioners. Patients and families offer invaluable and underutilised information about their health status. It is at the moment of hand-off reports where nurses, patients and their families may be brought together to engage in information exchanges. Research shows patients involvement in their health care is linked to improved health outcomes and enhanced patient safety29. A systematic review by Schwappach30 found overall support for patients assuming a more active role in their health care, particularly in those aspects of their care that are presumed to be routine, such as the transmission of their health information. Findings also show that patients are more willing to be engaged in their care if they feel supported by members of the health care team. This systematic review does not question the significance of hand-off reports or the prevailing concerns that are known to jeopardise both patient safety and the efficient use of time. The main objective of this review is to further refine what is known about patient and family presence during hand-off reports. The Cochrane and Joanna Briggs Institute (JBI) libraries of systematic reviews were searched finding no previous systematic reviews on this topic, either published or identified as being underway. The omission of a systematic review on patient presence during nurses' hand-off reports is a gap in the literature and is contrary to the notion of patient engagement. Since the most alarming challenges are identified within hospitals, namely acute care settings, the focus of this systemic review is to analyse research that is relevant to hand-off reports in this context. In addition, since nurses are the largest group of health care professionals, delivering a significant portion of patient care in hospital environments31, nursing will be the discipline that is analysed within this systematic review. A systemic review of the viewpoints of nurses, patients and family members on patient presence during hand-off reports will help health care professionals, including nurses, refine hand-off report practices. Such changes may subsequently provide more meaningful and comprehensive information exchanges which, in turn, could potentially improve patient-care delivery outcomes. Inclusion criteria Types of participants The review will consider studies that include patients, families, and nurses' experiences of patient presence during hand-off reports, or patients, families, and nurses' beliefs, opinions, and desires related to patient presence during hand-off reports. All patients will be included regardless of age, health condition, reason for the hospital admission, or experiences with hand-off reports. Families will include any individual or group identified as family within the materials under review. Nurses will include all licensed nurses including registered nurses, practical nurses, nursing assistants, nurse researchers, and advanced practice nurses. Studies and texts presenting emergency department and operating room settings will be excluded. The former, because they may not include patients that are admitted to hospital, and the latter, due to the level of consciousness. Types of intervention(s)/phenomena of interest The qualitative component of this review will consider studies that investigate the experiences of patients, families and nurses pertaining to patient presence during hand-off reports. The quantitative component of the review will include surveys of beliefs, opinions, views that answer review questions two, three and four. The textual component of this review will consider publications that describe the experiences, beliefs, opinions, views of patients, families and nurses of patient presence during hand-off reports. For this systematic review hand-off reports are defined as transfer of information amongst health care providers between shifts. Patient presence is defined as hand-off reports that transpire while the patient is in attendance. Types of studies The qualitative component of this review will consider qualitative evidence including, but not limited to ethnography, hermeneutics, phenomenology, grounded theory, narrative inquiry, and action research. The quantitative component of the review includes surveys of beliefs, opinions, views that answer review questions two, three and four. The textual component of the review will consider expert opinion, discussion papers, position papers and other text. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilised in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. A second search using all identified keywords and index terms will then be undertaken across all included databases.Third, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Studies published in any year will be considered for inclusion in this review. The databases to be searched include: CINAHL Cochrane Library Embase Google Scholar Health Source: Nursing / Academic Edition Knowledge Network Scotland MEDLINE ProQuest Nursing and Allied Health Source PsycINFO PubMed Science Direct Scopus Web of Science The search for unpublished studies will include: Google Mednar New Zealand Nursing Research Database OAIster ProQuest Dissertations and Theses science.gov Scirus Theses Portal Canada Virginia Henderson International Nursing Library Initial keywords to be used will be: handoff (and its variants: handoffs; hand-off; hand-offs; hand off; hand offs) handover (and its variants: handovers; hand-over; hand-overs; hand over; hand overs) signoff (and its variants: signoffs; sign-off; sign-offs; sign off; sign offs) shift report (and its variant: shift reports) bedside report (and its variants: bedside reports; bed-side report; bed-side reports) nursing report (and its variants: nursing reports; nurse report; nurse reports) patient room (and its variants: patient's room; patients' rooms) patient bedside (and its variants: patient's bedside; patients' bedsides; patient's bed-side; patients' bed-sides) patient attitude (and its variants: patient's attitude; patients' attitudes) patient perspective (and its variants: patient's perspective; patients' perspectives) patient view (and its variants: patient's view; patients' views) patient centered care (and its variant: patient centred care) family attitude (and its variants: family attitudes; attitude(s) of the family) family perspective (and its variants: family perspectives; perspective(s) of the family) patient view (and its variants: patient's view; patients' views) point of view (and its variant: points of view) family centered care (and its variant: family centred care) consumer participation Assessment of methodological quality Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the JBI Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using standardised critical appraisal instruments from the JBI Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-QARI (Appendix II). Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II). Textual data will be extracted from papers included in the review using the standardised data extraction tool from JBI-NOTARI (Appendix II). Data synthesis Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form. Quantitative papers will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Textual papers will, where possible, be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorising these conclusions on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the conclusions will be presented in narrative form. Conflicts of interest No conflict of interest.