This is another guest blog from Dennis Taylor, RN, DNP, ACNP-BS, FCCM of Lexington and current president of the NC Nurses Association.
We are once again excited to bring you content from Dennis Taylor, RN, DNP, PhD, ACNP-BS, FCCM of Lexington and current President of the North Carolina Nurses Association. Thanks to Mr. Taylor for contributing, please enjoy his thorough discussion of ‘Nurse Handoff Communications’.
It is a given that nursing is shift work. That said, there may be several healthcare professionals that are involved with the care of a patient every day. The coordinator of that care may change from day to day and often hour to hour. So, how do we assure accurate and complete information gets communicated to those who may be caring for patients?
The Joint Commission reported that 70% of sentinel events were caused by communication breakdowns. Poor quality and incomplete handoffs play a role in 80% of preventable adverse events.
Shift handoff has become a very formalized process at many healthcare institutions. It often includes the patient or family member of the patient and done at the bedside. For patients that are being seen in an outpatient setting, detailed notes of assessment, treatment plan and future care needs to be very detailed and documented for others to review.
How do I assure that I am communicating the correct information to a patient or designee?
The handoff communication process differs depending upon the setting of your practice. In the In-Patient, Long-term acute or chronic care, or rehabilitation settings, the process should be formalized and include the following information:
The real key to reducing the risk of negligence and charges of inappropriate or poor care of the patient is timely and effective communication with the patient (or healthcare designee) and the entire care team. Our job is not to know all of the answers to possible questions that a patient or family member may ask – it is our responsibility to be responsive to their questions and attempt to find out the answers to their questions. Patients and families that feel their care team is truly engaged and responsive to their needs and questions are much less likely to want to bring legal action against a care provider.
The SBAR method is being used in many organizations for effective communication. It stands for Situation, Background, Assessment, Recommendations/Request. This is one way to communicate information in a brief and succinct fashion.
Documentation is just as important – it is often taught, “If it was not documented, it was not done.” Any significant change in patient status, including significant changes in vital signs or treatment plans/decisions need to be documented in the patient’s medical record. Accurate documentation and assessment, as well as good documentation of events and those with whom the situation was discussed and decisions/actions taken will demonstrate that the healthcare provider has taken steps to address the clinical and psychosocial needs of a patient.
A big thank you again to Dennis Taylor for his contribution to nursing in North Carolina and for taking the time to help educate nurses by providing us with his great insight. Be sure to check out our website with our other blogs here.