REVISIONES

 

The Handover: A Central Concept in Nursing Care

El cambio de turno: Un eje central del cuidado de enfermería

 

 

Guevara Lozano, Maryori* and Arroyo Marles, Ligia Patricia**

*Masters in Nursing. Professor, School of Nursing and Rehabilitation, University of La Sabana. Email: maryorygl@unisabana.edu.co
**Specialist in Management in Health Institutions. Director, Clinical Nursing, University of La Sabana. Colombia.

 

 

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ABSTRACT

With the objective of reflecting on the value of the shift change as a central moment and concept in nursing care, a literature review was conducted in Spanish, English, and Portuguese using the following descriptors: cambio de turno [shift change], informe de turno [shift report], pase de guardia [handover], traspaso de información [information exchange], and communication (restricted to nursing reports). The search was conducted using the following databases: SciELO, Ovid, Science Direct, Redalyc, Publindex, Lilacs, EBSCOhost Academic Search Premier, Pubmed, and Dialnet; a total of 80 articles were reviewed, of which 50 were selected because they satisfied the inclusion criteria.
The search results showed a large quantity of information on concepts, types, characteristics, and barriers, emphasizing how important it is for the discipline to understand the significance of the handover in daily practice.
In conclusion, one should reflect on the importance of continued professional growth, changes, processes, and procedures; moreover, one should ensure that the shift report is not only a momentary but also a necessary opportunity to educate and perform monitoring, evaluation, and feedback to allow improvement of the groups and encourage daily practice. The literature review revealed a tendency toward qualitative studies and a lesser proportion of quantitative studies, in addition to limited investigations on best practices, their evaluation, and the efficacy of protocols and structured guides- all of which contribute to daily practice in warm, high-quality care.

Key words: Shift change; Handover; Nursing care.

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RESUMEN

Con el propósito de reflexionar acerca del valor del cambio de turno como momento y eje central del cuidado de enfermería, se realizó una revisión de la literatura en idioma español, inglés y portugués, a partir de los descriptores: cambio de turno, informe de turno, pase de guardia, traspas de información, y comunicación (circunscrita a informes de enfermería). La búsqueda se hizo en las bases de datos SciELO, Ovid, Science Direct, Redalyc, Publindex, Lilacs, EBSCOhost Academic Search Premier, pubmed y Dialnet; se revisaron un total de 80 artículos de los cuales se seleccionaron 50 que contenían los criterios de inclusión.
Los resultados de la búsqueda evidenciaron gran cantidad de información frente al concepto, tipo, características y barreras, destacando la importancia que tiene para la disciplina comprender su significado en la práctica diaria.
En conclusión, se debe reflexionar sobre la importancia del permanente crecimiento profesional; los cambios los procesos y procedimientos pero aún más ratificar que el informe no es una oportunidad de un momento, es necesario educar, realizar seguimiento, evaluación y retroalimentación para permitir mejoras de los grupos y fomentar su práctica diaria. La revisión de literatura muestra una tendencia en estudios cualitativos y en menor proporción cuantitativos, además de escasa investigación en mejores prácticas, evaluación de las mismas y la eficacia de los protocolos o guías estructuradas, que contribuyan a través de la investigación a la práctica diaria al cuidado con calidad y calidez.

Palabras clave: Cambio de turno; pase de guardia; cuidado de enfermería.

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Introduction

Communication has always been a vital element or aspect of the nursing care process, especially during the transfer of information that, with the passage of time and introduction of scientific and technological advances, has led to a new focus on the delivery of information with quality and warmth. The shift change or handover is a key moment of care for guaranteeing the continuity of care and the patient's safety; it is defined as a report or ritual given when the nursing professional transfers the responsibility for the patients and what has been done in his/her shift to another that is arriving.

With the objective of reflecting on the value of the shift change as a central moment and axis in nursing care, and with attention to the safety of the patient and the continuity of care, a systematic literature review was conducted. This article presents the results of this review, examining the concept, its characteristics, and a proposal for optimizing the process and the inclusion of the patient and his/her family as active participants in the care. It also describes a shift report experience in the Clinical University of La Sabana.

 

Method

A literature review was conducted in Spanish, English, and Portuguese using the following descriptors: cambio de turno [shift change], informe de turno [shift report], pase de guardia [handover], traspasó de información [information transfer], and communication (restricted to nursing reports). The search was conducted using the following databases: SciELO, Ovid, Science Direct, Redalyc, Publindex, Lilacs, EBSCOhost Academic Search Premier, Pubmed, and Dialnet, as well as a manual revision of basic foundations in nursing books and two protocols from Columbian health institutions. A total of 80 articles were reviewed, from which 50 were selected because they satisfied the following criteria: shift change or handover as a central theme, information transfer as communication in nursing, nursing care, and improvement suggestions. The characteristics of the articles included the following: topic reviews; thoughtful, investigative articles of a qualitative and quantitative nature; and protocols or structured guides. A final review of the chosen documents was conducted, identifying how they addressed the theme in accordance with the keywords and the stated purpose.

 

Results

Based on the qualitative analysis of the concept, the characteristics, and improvement plans-examining shift reports or shift changes by nursing professionals in their daily practice-a tendency toward qualitative studies and, to a lesser extent, quantitative studies, with limited investigations into best practices, their evaluation, and the efficacy of protocols and structured guides, was observed. A total of 80 articles were collected, from which 50 were taken that contained the inclusion criteria, published between 1999 and 2013. Of those, 70% (35) were qualitative investigations, and the remaining 30% (15) were quantitative. Furthermore, limited investigation was evidenced in Spanish-speaking countries; only 6% of the articles were in Spanish. The content analysis generated the following results: identification of the concept, its characteristics, and barriers in all of the articles; ethics in three articles; the importance of the patient's and family's participation in 10 articles; and improvement strate gies in 20 articles that are described below.

The Concept of a Shift Change

The literature review showed that the use of the concept is standardized and, in many cases, practiced literally. Nogueira ⁽¹⁾ defined shift change reports as verbal reports with the objective of relating what occurred and what care was given to a patient during the previous shift so that the next shift's members know the fundamental aspects of the patient's present condition, in an effort to guarantee continuity of care.

Hays outlined how the transfer of information from the personnel leaving to the personnel coming in occurs⁽²⁾. The report could be understood as a complex and important part of the professional practice that attends to various objectives, including communication, the supply of current information, and the continuity and quality of the patient's care⁽³⁾-as well as the assignment of responsibilities and routine duties. Sexton defines it as an "important process of information exchange to secure and maintain the continuity and quality of attention in favor of the patient's safety, which happens within legal regulations of the professional practice." Similarly, it affirms that one of the main difficulties is the fact that the report often lacks form or structure; therefore, the information that it transmits is irrelevant, repetitive, and speculative, jeopardizing the process in some cases due to lack of directives⁽⁴⁾.

Nursing foundations books refer to it as a vital report for the continuity of care in which a group of nurses who are leaving can report the updated patient information to the entire entering group. The report should be complete and concise, with no regard for the method employed, focusing on the patient (following a specific order) and not a moment for social conversation⁽⁵⁾.

In 2009, Terry defined the report in terms of responsibility and accountability for a patient's care, which is transferred from one nurse to another, where the communication is linked to the safety of the patient and the continuity of his/her care⁽⁶⁾. In the study, the author found that flaws in this process interfere with continuity of care and that the spaces and time frames for completing the report vary from one institution to another.

The importance of the shift change in the process of caring for patients has motivated the development of protocols to standardize the process in different health institutions, even though the literature shows that the results obtained are not satisfactory^(7,8). In the majority of health institutions, there are protocols and guides for the shift change, which are defined as activities that guarantee the patient's continuity of care by nursing personnel and attendance to elements necessary for patient care, such as a service inventory or a report of any change that has occurred⁽⁹⁾. Simultaneously, it is described more explicitly as a procedure through which one receives a report on each one of the patients that includes diagnosis, evolution, treatment, activities, and completed and pending exams⁽¹⁰⁾.

A shift report should be formulated as a method of providing relevant information to orient daily practice and direct care. The report should, therefore, be informative and educative for the nurses, patients, and their families. It should convey not only details about the patient's state and treatment (known or unknown to the patient and family) but also care plans.

Characteristics of the Shift Change: Regularity, frequency, duration, location, participants, and types of information

The shift change is characterized as being a routine, daily event that is performed in the morning, in the afternoon, and at night⁽¹¹⁾. Staying within the assigned time is one of the reoccurring challenges for nursing professionals, with an average time for shift changes ranging between 15 to 45 minutes, depending on the number and condition of patients⁽⁴⁾. Athwal et al. and Hays have principally addressed the types, content or characteristics, advantages, and disadvantages^(2,12) as well as tests with changes in the process in front of the patient and the patient's family⁽¹³⁾. Riesenberg et al. emphasized the complexity of the shift report and difficulties associated with it, such as the lack of communication and inadequate transfer of care⁽¹⁴⁾.

In the shift report, information about the patients' physical, psychosocial, and spiritual aspects, as well as medical facts, opinions, and impressions, are shared to resolve care problems, to give and receive help, to construct relationships, and to manage conflicts. The report should be sufficiently broad to be holistic in nature and to consider the patient's long-term care objectives, but it should also be sufficiently specific to meet short-term goals and to offer individual preferences for satisfying the patient's needs and not the needs of the nursing professionals.

Therefore, the shift change signifies a time for communication to promote care, safety, and best practices⁽¹⁵⁾ with the aim of eliminating or mitigating risks to the patient⁽⁾. Additionally, personal significance and socialization can be an objective or personal goal for welcoming patients and their families during the handover because the shift report may have an emotional significance⁽⁶⁾. An example of this is the nurses' participation in the difficulties and anxieties in this time of care, which is understood as a time or space for interrelation among the nursing staff, the patients, and the patients' families to generate, give, and strengthen the nursing care⁽¹⁷⁾.

In this way, the shift change becomes a time to connect with the patient, his/her family, and the rest of the staff to resolve difficulties that have occurred in the course of the shift with the entire team and, simultaneously, to socialize, sharing what was resolved and what is pending. The important thing is that it does not become a routine that hides the times for the development of the process; we are people taking care of other people, and, for this reason, one cannot be ignorant of these personal good intentions. Similarly, nursing stations, conference rooms, patients' headboards, and hallways are the places where the shift report is carried out⁽¹⁸⁾. The most common forms are the oral and written report, followed by the recording, which has the disadvantage of zero feedback⁽⁵⁾, and, finally, one with the patient. In that form, the patient is included and welcomed into the report given to the entering nurse; the literature agrees that this is the best way to complete the shift report, especially for the night shift.

Barriers in the Transfer of Information

In 2010, Riesenberg et al.⁽¹⁴⁾ completed a systematic literature review that identified barriers to the adequate transfer of information, which they classified into eight categories: communication barriers, problems with standardization or policies that ensure the process, difficulties with technical equipment, difficulties with the complexity and number of patients, the training and education of personnel, and human factors. Despite the known negative consequences of inadequate transfers of information, very little investigation has been conducted to identify best practices. There is a notable coherence in the suggested strategies, but there is a lack of evidence to support them⁽¹⁹⁾.

The traditional methods tend to be long, incoherent, and incorrect regarding the patient's information; the content sometimes deviates to irrelevant declarations or a priori judgments that carry negative prejudices from the professionals toward the patients⁽²⁰⁾. In this way, one can convert the report into a vehicle for disrespect, lack of communication, unconscious negativity, and projections (or unverified facts) that can weaken interpersonal relationships and ethical values⁽²¹⁾.

Another factor that can influence the shift change and handover are distractions, including parallel conversations, the movement of carts and supplies, clothes and food, cleaning machines, the high volume of radios and televisions, telephone calls, interruptions by medical and support staff, and conversations in the corridor and nursing center-situations that are more common during shift changes in the morning and the afternoon, given that they are hours of greater circulation⁽²²⁾.

Incomplete information, distractions, and errors in communication⁽²³⁾ during the shift change and handover are the principal causes of adverse events, such as medication errors, prolonged hospital stays with unnecessary diagnostic tests, and patient dissatisfaction⁽²⁴⁾. This conduct provokes personnel actions that do not contribute to a good process and becomes a vicious cycle that impacts the handover itself, given that it generates negative responses that do not contribute to the continuity and professional critical judgment for prioritizing and organizing care. Examples of these problems include misunderstood or omitted information, an extension of time for the handover, a build-up of insubordination, indifference, lack of motivation, lack of respect among colleagues, and an interruption in communication⁽¹⁾.

Nurses' work schedules are another predisposing factor in the efficacy and efficiency of the handover, using the start and end times (which, in many cases, barely overlap by 10 minutes between the morning-afternoon shifts and the afternoon-night shifts) as a reference. Evans et al. confirmed that the absence or lack of available time for this process affects communication in the handover⁽²⁵⁾. They suggest that time issues can negatively influence the performance of the nursing group as a mouthpiece for the information, which, consequently, can have implications for the care and management of the service.

The Ethics of the Handover

Discussing the ethics of this moment in care is an important and frequently referenced point in the literature^(26,27). Indeed, it is one of the principle duties of nurses to weigh the benefit and responsibilities of sharing the information that is in their hands with others. As defenders of patient and professional privacy, nursing professionals should be clear on the intentions of sharing facts and opinions and, similarly, determining the manner of management of relevant, confidential information for the patient's care. This implies value judgments concerning what are important for his/her care and what they are authorized to share and under what circumstances. Similarly, it implies discerning what information to divulge within the context of the collegial relationship and what teamwork requires⁽²¹⁾.

Nursing professionals' information management and decision-making should be based on principles associated with fairness, respect, dignity, and commitment-and not necessarily on their own needs or society's needs. Indeed, moral considerations change with time because the level of reasoning changes, resulting in cognitive maturity, practical experience, formal education, and the environment⁽²⁸⁾. In addition, it is expected that nurses adhere to values of the professional practice's ethical codes, a scheme of principles that demonstrates the profession's members' responsibility to society. The Code of Ethics⁽²⁹⁾ for Colombia summarizes nurses' values and rights to follow for making ethical decisions and providing high-quality nursing care.

With this understanding, the shift report should be seen as a vehicle for sharing values, beliefs, perceptions, judgments, and, above all, respect. When a shift change is established in a manner founded in ethics, responsibility, and the quality and safety of care, relationships are improved, the efficiency and functioning of teamwork are strengthened, time is optimized, and incorrect or insufficient information is not passed on.

Importance of Patient and Family Participation

Evidently, the process has not traditionally included patients and their families; in fact, families have often been required to leave the room during the process⁽⁶⁾. In the studies completed between 2006 and 2007^(30,31), it was demonstrated that nursing professionals see completing the shift report with patients as a serious problem because it may lengthen rather than shorten the time in the event of asked questions and due to interaction with them and their team, which can result in longer reports.

However, nursing professionals do not realize that those same patients and their families are administrators of their own care in a hospital stay, and they are not given the opportunity to listen to and participate in the exchange of information^(22,32). Similarly, the sharing of information between shifts is encouraged by means of the patient's direct observation of both nurses rather than generating assumptions; when the report is not completed with the patient, the opportunity to include the patient and family in planning care is lost.

Nevertheless, while many nurses now know the value of reporting face-to-face with the patient-and practice it on a routine basis-it continues to be relatively uncommon.

Despite the anxieties concerning the implementation of the shift report with the patient, there are studies that demonstrate the benefits of this process^(22,30,33). One benefit is the nurse's ability to confirm the information immediately by viewing the patient and obtaining a baseline assessment to compare changes during the shift⁽³⁴⁾, thus planning and prioritizing the patient's care.

Evidence suggests that patients who are better informed are less anxious, more adherent to their care, more autonomous in their treatment and goals, and feel satisfied^(27,35). Additionally, healthcare costs are reduced by the self-management performed by patients and the more efficient use of resources. The benefits of carrying out the handover with the patient include not only taking the patient into consideration with a more holistic and prioritized care but also greater professional satisfaction, which encourages teamwork across all shifts, promoting personal responsibility and universal commitment⁽³⁰⁾.

It should be clarified that the communication of information is a right for the patient and his/her family⁽³⁶⁾; it is regulated by Law 911 from 2004, which regulates the care process⁽²⁹⁾, assuring a holistic view that seeks to attend to the physical, social, mental, and spiritual dimensions to provide nursing care that understands the environment and the patient's needs with dignity and cultural respect, without discrimination. This guarantees a dialogue the foundation of which resides in the nurse-patient-family interrelationship as an essential element of the care process, which assures effective, respectful communication based on harmonious interpersonal relationships in which the patient and family freely and confidently express their needs and expectations for care⁽³⁷⁾.

In that regard, there are various articles that support the authentic search for care that is centered on the patient's and family's needs and expectations with the objective of generating the development of a culture of inclusive education, one that is caring and one that recognizes and allows the present participation of patients who are accustomed to a certain level of service and a higher degree of power to decide what they want and how they want it. In contrast to their passive predecessors, modern patients ask for care interactions in which there is a large quantity of information. They are not prepared to accept the "doctor knows best" focus of the past. In general, patients (and sometimes, more importantly, their families) are increasingly vocal and demanding with respect to the quality of care that health institutions offer.

Another benefit that the interaction has is promoting the nurse-patient relationship⁽³⁰⁾. As a result, the staff works as a team and improves the professional image of the nurse. By working together, the patients are witnesses to a secure and professional transfer of responsibilities. Patients can ask questions or contribute information to the discussion. Allowing the professional and the patient to have the opportunity to share information promotes participation and improves satisfaction⁽³³⁾; it builds relationships among the staff members, demonstrating a care centered on the patient and not on the means to an end.

In this way, patients and families can communicate a personal testimony of the nurse's and health institution's professionalism. It is a personal opportunity for another nurse with less experience to follow a model. It also influences the collection and clarification of erroneous information that was shared during the shift report, in addition to educating patients and families with new information.

Breaking the traditional routine of the shift report is a challenge for nursing professionals; in short, it is not taken into account that patients and their families are guarantors of safe care and care experience. The advice that we want to emphasize in this article is that this process of reporting is be new and challenging, aiming to optimize the continuity of care, strengthening the nurse-patient relationship and the work of the healthcare team.

Strategies for Improving the Shift Change and Handover

It is proposed that, based on the literature, the following strategies could be useful in the optimization of the process based on the barriers presented above:

- Nursing Perspective: It is important to define a vision and a concept of care that relate to the mission and vision of the institution that supports the daily practice at this point in the patient's care. It is important for them to be discussed in a consensus with every unit's professionals and branches and that the importance of patients' and relatives' access to the information in the handover is recognized. The health organization's vision of care should contain the relationship between care results, patient and family satisfaction, and participation in the nursing care process and making⁽³⁹⁾.

- Preserving Privacy and Confidentiality: First, a change in professional practice that can also lead to a paradigmatic shift is required, given the characteristics and disadvantages in time, space, personnel, and one of the issues to which the literature refers most: privacy in the confidential management of information. Confidential information is divulged inadvertently during the entire hospitalization process by the entire healthcare team; these revelations are not intentional but rather a consequence of having common spaces. In fact, the way to limit this is during the same shift change process, with the consciousness that one is with the patient, planning, with anticipation, the type of new or sensitive information that could be shared before or after being with the patient or whether it warrants being discussed later in private.

- Patient and Family Participation: In many cases, spaces are shared, and this results in the professionals' concern with the development of the report with patients and relatives; but, this should not prevent the nursing professional from hearing them, particularly for planning their care, making decisions, and meeting necessities that contribute to the continuity of care and the safe care of the patient. During admissions, it can be asked whether the patient or a relative wants to participate in the process. To facilitate patient and family participation, optimize time, and preserve intimacy and individuality, it is recommended that a general report is done with the nursing staff for 5-10 minutes at the beginning of each shift in the nurses' station or in the conference room to reduce difficulties in managing confidential information.

Terry⁽⁶⁾ suggests that a limited amount of information be provided, such as basic diagnoses, safety questions, and care questions that everyone should know. After this, a report should be given with the patients in their rooms to share what has occurred during the shift, the care plan, and invite the patient and family to participate in the discussion. During the report, there is a safety check of fluids, intravenous lines, drains, medications that are in continuous infusion, and everything concerning scale measurements for the safety of the patient and inventories-all of which can be delegated to the nurse's working group so that the professionals concentrate on the care needs of the patients.

For management and inclusion of patients, Douglas and Cairns^(40,41) suggest carrying out the report at night, which includes three steps. The first is involving the patient and his/her preference of having or not having family members at the report; this also encourages the patient's confidence in the management of his/her care. Second, topics related to their care should be discussed, such as clinical updates (for example, laboratory results, wound care, and medications) as well as the goals for the next shift. Finally, bidirectional communication should be facilitated. Similarly, as with any new process, one should provide communication skills education to the nursing professionals and the patients; this education and support from personnel and patients should be permanent.

For the time required for the report with the participation of the patient, negotiations should be outlined to satisfy their needs and the need of their families in the process; one option is to make a note of comments and return after the report to clarify, satisfy needs, and ask for approval. Another possibility for saving time involves the patient and the family meeting with two nurses⁽⁶⁾. In fact, professionals should concentrate on the patient and the report and not the circumscribed problems associated with it, which can be managed by coordinating wards.

- Standardization: Standardization is another strategy that positively influences the process; the use of logs and standardized formats⁽¹²⁾ for information is frequently used and facilitates or diminishes the possible variability in the report's communication. In that way, one can work with the patient and families to determine what other aspects of the care should be included in the report template. When these formats are developed, non-technical terms should also be included, for example, plans for special visits or what the patient expects-items that are necessary for his/her care and that are not in the institution-or aspects of administrative procedures.

- Availability of Resources: Regarding the availability of material resources, these should be readily available in a manner similar to when a new team is introduced. To improve the documentation system, the use of information technology and wireless modes of communication⁽⁴²⁾ is suggested; that is, they should be explored as a means of improving the shift change process and, consequently, health outcomes and patient safety⁽³⁴⁾. The use of technology, such as mobile Android^® systems or tablets, would allow better recording and secure updating of the information and prevention of errors that contribute to incidents and adverse events.

Analysis of an Experience - The Nursing Care Model at the Clinical University of La Sabana

Based on the analysis of the considerations related to shift change above, with an emphasis on care management, continued improvement, and superior levels of quality, various unanswered questions arise from the nursing practice at Nursing Management in the University of La Sabana Clinic: Beyond the shift change as a m oment of care, how can a person's constant state of health and illness be consolidated and adapted to the daily practice of nursing? How can the use of technology to facilitate efficient time management, the monitoring of care plans, the nursing interventions, the control, monitoring, and prevention of risk, and the summary of patients' experiences be incorporated in practice? How can the necessity of shared responsibility for nursing be instilled to make the handover a ritual, a rewarding function of the nursing practice? Finally, how can the institution secure the patient's and family's participation in the presentation and the continuity of information and live experiences, with the participation of the healthcare team protecting and preserving the principle of confidentiality?

To answer these and other care management concerns, a Nursing Care Model proposal for the University of La Sabana Clinic in Chía, Colombia, was initiated in 2012 as part of the ontological vision and epistemological concept of nursing care (elaborated in the teachings of the University of La Sabana and the nurses of the Clinic)-a proposal that, among other things, included the concept of the handover as a nursing care moment in the Clinic and its optimization.

Theoretical Focus of Nursing Care in the Clinical University of La Sabana in the Shift Change.

Nursing care should be provided in an integral manner and with a vision of reciprocity⁽⁴³⁾, in which people are conceived of as changing beings who confront situations that affect or improve their constant state of health-illness daily; that is, as a process of permanent and active reconciliation in which the professional should be conscious of providing care for adjustment, an intentional, holistic, and interpersonal response that is developed through cognitive processes and professional abilities that seek to improve the individual's adjustment as a result⁽⁴⁴⁾.

Care implies in itself a time and space, in addition to a knowledge of each patient, in terms of attitude, aptitude, and motivation; furthermore, it implies a reciprocal, unique, authentic relationship between the nursing professional and the patient that is capable of generating confidence, security, and effective help. The above emphasizes the importance of the information transfer or shift change as a moment of care in which the concept of care is lived as a fundamental part of the daily practice with a curricular, theoretical focus.

With a basis in this concept of care, an assistance teaching proposal was elaborated between the School of Nursing and Rehabilitation and the Nursing Management Unit of the University of La Sabana Clinic. It sought to give consistency to the exploration of strategies for incorporating technology management into the daily work of nursing as one of the four central ideas of the evaluative model of the system that was unique to health accreditation, a process that the Clinic had initiated.

The shift change and handover were considered a moment of care and the project's point of departure, where the coming together of the entire human team was composed of qualified persons in agreement with the common objective. This objective consisted not only in providing information related to the patient but also in evaluating and guaranteeing the efficacy of the services in terms of best utilization of resources and quality in the satisfaction of the patient's needs and expectations for the shift by means of the implementation of a log, the planning of nursing care, and the continuity and evaluation with the HOSVITAL system (the Clinic's information platform). The Hospitalization area was selected for the fulfillment of the project due to the characteristics of the care process, the clinical conditions of the patients who stay, and the application of the nursing care model proposed.

The management Project was carried out in three phases:

1. An initial Planning and Design phase for the normalization and standardization of the information: A management project led by the Head, Director, and Coordinator of nursing for the Clinic was carried out, advanced by a VIII-semester student in the School of Nursing and a focus group of nurses in the Hospitalization service, all of whom shared concerns about the matter, with particular motivations to address the empirical and theoretical knowledge of nursing and to apply, in a practical context, patterns of nursing knowledge to enrich the practice on the basis of theory. It must be noted that this focus group only recently became associated with the institution, with an open disposition for contributing, learning, and improving without restrictions on the proposed changes; their participation was determined by their status as prepared professionals, leaders with a focus on improvement, innovation, and change with a critical ability in the face of findings.

In this phase, an analysis from the nursing perspective was carried out with the whole group, while the literature was being reviewed and a first instrument was being produced, a manual log with 16 items that cover the following aspects: patient identification, subjective data (How is s/he? How does s/he feel?), nursing diagnosis, medical diagnosis, control of vital signs, respiratory devices, diet, nutritional devices, skin assessment (wounds, pressure sores, ulcers), elimination devices, laboratories, care plans, consultations, and pending.

Observations were made related to the time invested for the shift change and handover and the identification of improvement opportunities for specifying the information related to the following: paraclinical tests, the start of pharmacological treatments, changes in the therapeutic scheme, continuation of the care plan and the nursing care process, the identification of the risk of events and accidents associated with a lack of information, and the necessity of emphasizing the pain assessment and the identification of allergies in the patient's assessment.

2. In the second phase, the facial validity of the 16-item log was evaluated. With the focus group, 119 registries from each one of the different shifts in the months of September and October 2012 were analyzed from 12 shift-change and handover logs in the hospitalization service that were selected at random; the following data were found. It was evident that there was no clarity regarding what data should be completed in the log; in the part for the nursing professional, there was no record of vital signs. It could also be observed that of 119 patients, only 51 patients required a skin assessment; of those, 9 were completed, but the numerical scale for this assessment was not employed. Forty-two patients who needed the assessment did not receive it.

It could be observed that nursing diagnoses' records were being completed at a rate of 87% (corresponding to 104 records); nevertheless some of those did not have the correct form. Meanwhile, only 13%, corresponding to 15 records, were not done. Moreover, 104 records of medications were found in the log, versus 15 records that were not recorded. A total of 111 records of nursing care plans were recorded; nevertheless, many of these only indicate assistance with basic necessities and control of vital signs.

Based on these findings, the focus group made the following proposals: convert the manual instrument into a digital one with 24 items, including the treating specialty, the isolation classification, identification of allergies, and the Glasgow Coma Scale. Design an instrument for auxiliary nursing staff that includes the following: a record of vital signs, glucose readings, balance of liquids, changes in position, and a quantification of drainage and gastric residue. Leave only one box for the recording of the glucose readings and organize the instrument in the cephalocaudal form, given that there are difficulties or omissions of some data in the shift change and handover. Eliminate the box for medications because it is very rarely completed, which creates confusion; additionally, there are other, more effective means, such as the medication card and the medication delivery cart. Finally, combine the boxes for subjective and objective data in the box for nursing care.

Similarly, they expressed the difficulty of recording with the log given the low number of nurses assigned to an area (one nurse for every 12 to 14 patients), which extends the time spent on its completion and the extension of the content. Nevertheless, they expressed agreement that the advantage of the instrument is that it is a required formal record for the institution and a legal framework for the handover that allows institutions to have updated and complete information on the clinical condition, the patient's needs, and the prioritization of care, such as the pain and risk assessments.

3. The third phase consisted of the standardization of the instrument, a digital form throughout the service, the training, and the generalized use of the log by the twelve nurses from the Hospitalization service of the Clinic. A participative discussion with the nurses from each one of the shifts was proposed to investigate their perspectives concerning the log (strengths, aspects to include, and aspects to reevaluate). Similarly, the means for storing these logs, such as email and databases in Excel, and the implementation of the instrument for nursing aids were part of the coordination of the hospitalization service. After training and three weeks of application, there was another verification, which found the following: a significant increase in the recording of nursing diagnoses, pain assessments with the analogous numerical scale, laboratory updates, and care plans, including changes in their planning.

In addition, it was observed that the planning of the focus groups for evaluating the content of the log was considered good or excellent. Similarly, the quality of the log in terms of the creativity of the design, order, and content referred to personal and professional growth through usage of the instrument or log. This confirms what was shown in the literature and what they observed themselves in their daily practice, taking into account responsibility and the importance of the handover, which allows them to summarize the patient's medical history, monitor, and record completely or integrally to give continuity to the planned nursing care, facilitating comprehension and improving the handover.

The suggestions outlined propose training for the nurses who have recently become associated with the service in the correct use and storage of the log to provide an information summary document. Suggestions included going through the following with the nurses on the training days: the application of nursing diagnoses, the evaluation of the periodic processing of the logs, and the subsequent analysis of the information recorded to favor the application of nursing diagnoses and interventions, the timely identification of indications of unsafe care, and the suggestion of barriers that minimize care risks.

Similarly, suggestions included incorporating the shift change and handover as a moment of care with assigned and delimited times into the practice of the nursing groups. It should be thought of as a ritual or group activity that should not be interrupted and to which one should pay the utmost attention, preserving the principles of confidentiality, prudence, and respect, encouraging the participation of the patients and families.

 

Conclusion

In conclusion, one should reflect on the importance of continued professional growth, changes, processes, and procedures; but, moreover, one should ensure that the shift report is not only a momentary but also a necessary opportunity to educate and to carry out monitoring, evaluation, and feedback to allow improvement of the groups and encourage their daily practice. The literature review revealed a tendency toward qualitative studies and a lesser proportion of quantitative studies, in addition to limited investigations on best practices, their evaluation, and the efficacy of protocols and structured guides-all of which contribute to daily practice in warm, high-quality care. As leaders in the process, nursing professionals should be able to guide their development, critically and proactively, with a view to eliminating personal and environmental factors or barriers that interfere in a negative way with the process, guaranteeing the continuity, quality, and safety of the patients' care through an efficient handover.

By applying the concept, an adequate shift change provides nursing professionals with the opportunity to clarify and correct inaccuracies with the patient and the family and with their own colleagues, ultimately, decreasing errors and adverse events in his/her care and increasing the satisfaction of the patient. Their observations and contributions could be valuable for the patient's care; valuing the help of the patient and the family in an exchange of information is key and, in this way, his/her care transcends that moment in time.

 

Recommendations

Based on the literature review of the shift change in nursing and the empirical experience developed in 2012, it is recommended that, in the future, quantitative investigations that provide evidence to support the use of a specified structure, log, protocol, or method for the improvement of the shift report be carried out. The results of high-quality studies centered on factors such as the efficacy of protocols, improvement interventions, and the participation of the patient and family are urgently needed. Similarly, optimizing the report with the above strategies, particularly the participation of the patient and his/her family in warm, high-quality daily practice, is also needed.

 

Received: June 9, 2013
Accepted: September 8, 2013

 

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