Exploring Information Sharing Problems in Nursing Handover: An Activity Theory Perspective

The sharing of patient handover information between individuals and teams of nurses in clinical settings is a complex process that requires consolidation and integration of information from different sources and types of artefacts. The aim of this study is to identify the most critical information-sharing problems nurses experience during handover. Handover information-sharing problems are explored using Activity theory (Engestrom, 1987) as a lens to better understand the nature of these problems. A qualitative research approach was conducted to collect data from four units in a large Saudi Arabian hospital. Findings indicate that Activity Theory is a comprehensive theory to analyse a full spectrum of socio-technical handover problems. Findings further indicate that handover information sharing problems relate mostly to: 1) incompatible handover artefacts, 2) inadequate guidelines and training to conduct handover processes, 3) insufficient and fragmented documented information to share during handover and 4) nurses’ personal style

Doctor of Philosophy

dissertationQuality nursing home care is a national health concern. Projections of increasing residency rates are coupled with growing concern about nursing home staff capacity and ability to provide quality care. The Institute of Medicine Committee of the Future Health Care Workforce for Older Americans suggests that efforts are needed toward improving nursing home workforce skill. Nurses and certified nursing assistants (CNAs) comprise the majority of the nursing home workforce; CNAs provide 80% of resident care. Despite their significant role as direct caregivers, little is known about nurse-CNA interactional processes, including how they communicate. This relative lack of existing information suggested a need for better understanding of even fundamental communication processes from nurse and CNA perspectives. A grounded theory approach guided this study to gain understanding of nurse-CNA communication processes and factors that influence the processes from the perspective of nurses and CNAs when providing direct care to nursing home residents. Goffman's dramaturgical concept of front- and back-stages, supported by the premises of symbolic interactionism, provided an analytical framework for exploring nurse-CNA communication processes in the complex context of the nursing home setting. Data were obtained from observation, shadowing, and interviews of nurses and CNAs on two ~ 40-bed long-term care units in a nursing home. Systematic procedures 13 for inductive data analysis suggested that nurse-CNA communication processes were guided by four "rules of performance": (1) maintaining information flow, (2) following procedure, (3) fostering collegiality, and (4) showing respect. Nurses and CNAs communicated as opportunity arose in the midst of resident care and described their communication processes in relation to efficiency of care that was affected by the presence or absence of cooperation, initiative, and reciprocity. Role ambiguity stemmed from nurse-CNA hierarchical position associated with delegation and supervision; contextual ambiguity resulted from the dual purpose of the nursing home as a health care institution and the resident's "home." The interplay of "rules of performance" on the front- and back-stages of direct care should be considered in the development of contextually applicable policy and practice strategies that are relevant to nurses and CNAs providing care to nursing home residents

An Analysis of the Work System Framework for Examining Information Exchange in a Healthcare Setting

Lack of communication is a leading root cause of sentinel events (any unanticipated event in a healthcare setting resulting in a patient’s death or serious physical or psychological injury and not related to the natural course of the patient\u27s illness). Deficits in communication of essential information when patients transfer between different healthcare services can cause interruptions in the continuity of care, inappropriate treatment, and potential harm to the patient. Research has shown that providing the right information about the right patient to healthcare providers at the right time could eliminate up to 18 percent of the general adverse events. In this paper, we assess the applicability of the work system framework (WSF) to evaluate the health information-exchange processes that occur when patients are transferred from home healthcare services and nursing homes to hospitals. From our analysis, we identify possible improvements in both work practices and the flow of health information among healthcare providers. Further, we propose a modified work system snapshot template tailored for evaluating the health information-exchange process. The proposed modifications include changing the WSF terminology to healthcare terms (including patient safety indicators) and adding new performance measurement indicators that are relevant to healthcare

Master of Science

thesisThere is a high risk for communication failures at the hospital discharge. Discharge summaries (DCS) can mitigate these risks by describing not only the hospital course but also follow-up plans. Improvement in the DCS may play a crucial role to improve communication at this transition of care. This research identifies gaps between the local standard of practice and best practices reported in the literature. It also identifies specific components of the DCS that could be improved through enhanced use of health information technology. A manual chart review of 188 DCS was performed. The medication reconciliations were analyzed for completeness and for medical reasoning. The pending results reported in the DCS were compared to those identified in the enterprise data warehouse (EDW). Documentation of follow-up arrangements was analyzed. Report of patient preferences, patient goals, lessons learned, and the overall handover tone were also noted. Patients were discharged on an average of 9.8 medications. Only 3% of the medication reconciliations were complete regarding which medications were continued, changed, new, and discontinued; 94% were incomplete and medical reasoning was frequently absent. There were 358 pending results in 188 hospital discharges. 14% of those results were in the DCS while 86% were only found in the EDW. Less than 50% iv of patients had clear documentation of scheduled follow-up. Patient preferences, patient goals, and lessons learned were rarely (6%, 1%, and 3% respectively) included. There was a handover tone in only 17% of the DCS. The quality gaps in the DCS are consistent with the literature. Medication reconciliations were frequently incomplete, pending results were rarely available, and documentation of follow-up care occurred less than half of the time. Evaluating the DCS primarily as a clinical handover is novel. Information necessary for safe handovers and to promote continuity of care is frequently missing. Future improvements should reshape the DCS to improve continuity of care

Towards an understanding of the information dynamics of the handover process in aged care settings - A prerequisite for the safe and effective use of ICT

Background Poor clinical handover has been associated with inaccurate clinical assessment and diagnosis, delays in diagnosis and test ordering, medication errors and decreased patient satisfaction in the acute care setting. Research on the handover process in the residential aged care sector is very limited. Purpose The aims of this study were to: (i) Develop an in-depth understanding of the handover process in aged care by mapping all the key activities and their information dynamics, (ii) Identify gaps in information exchange in the handover process and analyze implications for resident safety, (iii) Develop practical recommendations on how information communication technology (ICT) can improve the process and resident safety. Methods The study was undertaken at a large metropolitan facility in NSW with more than 300 residents and a staff including 55 registered nurses (RNs) and 146 assistants in nursing (AINs). A total of 3 focus groups, 12 interviews and 3 observation sessions were conducted over a period from July to October 2010. Process mapping was undertaken by translating the qualitative data via a five-category code book that was developed prior to the analysis. Results Three major sub-processes were identified and mapped. The three major stages are Handover process (HOP) I “Information gathering by RN”, HOP II “Preparation of preliminary handover sheet” and HOP III “Execution of handover meeting”. Inefficient processes were identified in relation to the handover including duplication of information, utilization of multiple communication modes and information sources, and lack of standardization. Conclusion By providing a robust process model of handover this study has made two critical contributions to research in aged care: (i) a means to identify important, possibly suboptimal practices; and (ii) valuable evidence to plan and improve ICT implementation in residential aged care. The mapping of this process enabled analysis of gaps in information flow and potential impacts on resident safety. In addition it offers the basis for further studies into a process that, despite its importance for securing resident safety and continuity of care, lacks research