Handoffs are a known “trouble spot” when it comes to patient safety. As nurses, we participate in handoffs any time we transfer care to another provider, whether at change of shift, transfer to another floor or unit, or transfer to another facility. Errors that occur during these times can result from a variety of barriers, many of which are human factors, ranging from understaffing and interruptions to fatigue and information or sensory overload. 

The Joint Commission requires a standardized approach to patient handoffs; it is one of the National Patient Safety Goals (2006 National Patient Safety Goal 2E). During her presentation “Effective Handoff Communication: A Key to Patient Safety” at Nursing2013 Symposium, JoAnne Phillips, MSN, RN, CCRN, CCNS, CPPS, shared several acronyms that can be used to help guide a well-organized transfer of information and minimize errors and omissions during patient handoffs. 

SBAR + 2 (See also The Art of Giving Report and The impact of SBAR.)
  Introduction
  Situation
  Background
  Assessment
  Recommendation
  Question & Answer

5 P’s Model
  Patient
  Plan
  Purpose
  Problems
  Precautions

PACE
  Patient/Problem
  Assessment/Actions
  Continuing/Changes
  Evaluation

I PASS the BATON
  Introduction
  Patient
  Assessment
  Situation
  Safety Concerns
  the
  Background
  Actions
  Timing
  Ownership
  Next

What is the standard for nursing handoffs where you work?

References:

Cairns, L., Dudjak, L., Hoffman, R., & Lorenz, H. (2013). Utilizing Bedside Shift Report to Improve the Effectiveness of Shift Handoff. Journal of Nursing Administration, 43(3). 

Riesenberg, L., Leisch, J., Cunningham, J. (2010). Nursing Handoffs: A Systematic Review of the Literature. American Journal of Nursing, 110(4). 

Schroeder, S. (2006). PATIENT SAFETY: Picking up the PACE: A new template for shift report. Nursing2006, 36(10).  

Two days ago we received 2 cards in the mail. They come every year at this time. They are never late and there is always a personal note included.

My sons are 12 years old today. These cards, which have come every year for the past 11 years, are not from their grandparents or aunts or uncles. They are not from their friends or my friends. These cards are from one of the nurses who cared for them in the Neonatal Intensive Care Unit (NICU) after they were born prematurely.

So I write this to recognize the continued feelings of gratitude and awe that I have for one special nurse. How can I thank her for caring for my children when I wasn’t able? How can I thank her for showing my boys love and compassion when I couldn’t be there? How can I thank her for helping us through our most difficult days, weeks, and months?

My boys are grateful to receive these cards each year and to be remembered on their birthday; however I’m not sure they grasp how much the cards are appreciated by me and my husband. This day of celebration for our kids still brings mixed emotions to us, feelings which are understood by this special NICU nurse who reaches out to us each year.

As a nurse, I have not had a continued relationship with any patient after discharge, although I can think of several that I wish I had. How about you?

How do you greet a patient?
With a hello? A smile? An introduction?
Do you share your role? The plan for the day?
Do you make eye contact?
How do you address him or her? Mr., Mrs., or Ms.? By first name?

Then what do you do?
Do you wash your hands?
Do you write or type while talking?
Do you use therapeutic touch?
Those communication skills you learned in nursing school?

How do you include the family?
Do you share information?
Did you ask the patient if it's okay to do so?
Do you consider everyone's feelings?
Do you welcome visitors?

How about your assessment?
Do you go head-to-toe?
What questions do you ask?
Do you teach as you go?

How and when do you document?
Electronic health record? Paper chart?
Do you use a checklist?
As you go? Or toward the end of your shift?

How about medications?
Do you know the indications and recommended dosing?
How about interactions and adverse reactions?
Do you ask a colleague to check calculations?

How do you handle other interventions and procedures?
Do you provide privacy?
Do you explain what you are doing?
Do you ask if the patient has questions?
Are you able to answer?

Time to go home?
Did you get a break?
Did you eat? Use the restroom?
Are you ready to leave?

How do you say good-bye?

How many times has a patient said “I feel funny” or “I don’t feel right” and then proceeded to code shortly thereafter? That happened to me twice.

How many times have you felt pulled in different directions – between call lights, alarms ringing, medications to be administered, dressings to be changed, patient education to be provided, etc.? For me the answer is TMTC (too many to count!)

How many times has a patient deteriorated quickly or coded without any warning signs? I’d say several.

I wonder if during any of those times a patient was trying to reach out to me to say “I feel funny” or “I don’t feel right” and the opportunity to intervene passed without my knowledge because I was busy with other tasks.

Just thinking…

I wish that we had enough time during our day to just pause and listen. Wouldn’t that be nice?

Thank you to Julianna Paradisi of JParadisi RN's Blog for the Liebster Award nomination! These awards are a way for bloggers to get to know one another better, recognize one another, and share favorite blogs with their audiences. To continue the trend, I must share 11 things about myself, answer 11 questions asked by Julianna, and nominate 11 other bloggers and ask them 11 questions. So, here we go:

Eleven Things About Me
1. I speak Italian. My parents met when my dad was in the Air Force and stationed near my mom’s hometown in northern Italy. They married, had my brother, and then moved to the U.S. I learned the language from visiting our family and studying it in school. 

2. I like wearing glasses. I tried contact lenses but couldn’t get used to them. I own several pairs of glasses at any given time and like to order different styles online.

3. When time and acuity allowed, I thoroughly enjoyed washing patients’ hair, which was not usually an easy task in the Medical Intensive Care Unit. It was time consuming and messy, but I hope that someone will do that for me if I’m ever critically ill. 

4. I always, always wear a watch and am usually early for everything! It drives my family a little bit crazy!

5. I don’t like to style my hair, but if I have to, I usually straighten it, and then curl it. It makes no sense, I know.

6. NICU nurses are my heroes. For 2 months, they were lifesavers and caregivers to my twin sons who were born at 29 weeks.

7. I enjoy gardening. I find weeding relaxing and I don’t mind cutting the lawn or trimming shrubs. The best part, of course, is having fresh vegetables and herbs on hand all summer!

8. I still have many of my books from nursing school. They have been updated with new editions and even with all the information that is now available online, I still can’t part with them.

9. I love to fold clean laundry but hate to put it away.

10. Math was always my favorite subject. I took Calculus I and II as my electives in nursing school and now I enjoy tackling math homework with my kids, although they are learning things very differently than I remember!

11. Nurse bullying, horizontal violence – whatever you want to call it – upsets me tremendously, especially when it involves students or new nurses. We really need to support one another! We all started as beginners!

Eleven Questions From Julianna
1. Who was your childhood hero? My older brother! I would do anything to get his attention! I remember even begging my mom to make him say “I love you” to me. 

2. What book (s) have you read more than once? Firefly Lane by Kristin Hannah.  It’s a wonderful tale of friendship, but a real tear-jerker! Also, The $64 Tomato by William Alexander.  I read it every year while prepping our garden for the upcoming season. Even my kids like to hear excerpts of the author’s trials and tribulations in the garden!

3. If you could do one thing in your life over, what would it be? I probably would have done my MSN in acute care. I enjoyed women’s health and am glad to have that knowledge and experience, but I think my real passion is critical care.

4. In one sentence or less, how would you describe yourself? This is tough! Ok, here goes… I am a mom, wife, daughter, sister, and aunt who thrives on being with and caring for others.

5. What is your favorite way to exercise? Walking with friends. It’s a great way for us to catch up on each other’s lives and put in some miles!

6. Name one person from any era, dead or alive, you would like to meet. Mother Teresa. 

7. What is your secret talent? I can tap dance; took lessons for 13 years!

8. Do you ever dance to music when no one is watching? Yes, but it’s definitely more fun when my whole family gets into it!

9. What is your all-time favorite TV show? Friends.

10. What TV show theme song do you know by heart? So many! Friends, Cheers, Brady Bunch…. Also, thanks to my kids – Phineas & Ferb and Good Luck Charlie. 

11. What is one ability you wish you had, possible or not? I wish I could control time – the possibilities are endless…

Eleven Nominations
These are my favorites – enjoy! (Full disclosure- two are LWW journal blogs)
Nursetopia
Nurse Story
Correctional Nurse.net
Infusion Nurse Blog
Nursing Staff Development: Behind the Firewall
ANS: Advances in Nursing Science Blog
AJN’s Off The Charts
RNspiration
3cs: coffee, children, and cancer
At Your Cervix
Crass Pollination: An ER Blog

Eleven Questions for My Nominees
1. What makes you laugh?
2. Have you ever written for publication?
3. What was your first nursing job?
4. What is your favorite blog post that you’ve written?
5. What’s your favorite TV or movie quote?
6. What is your biggest fear?
7. Do you sing in the shower? If yes, do you have a favorite genre or song?
8. What’s your favorite vacation spot?
9. Can you describe your best memory of nursing school?
10. When did you know you wanted to become a nurse?
11. What do you find most fulfilling about being a nurse blogger?

I just spent a wonderful long weekend in Nashville, Tennessee at Nursing Management Congress 2012. What a great city, great venue (Gaylord Opryland Resort and Convention Center), and great event! I learned a lot, connected with lots of nurse managers and executives, and enjoyed my surroundings. I have lots to share with you over my next few blog posts, but I’m especially excited to share the following idea which was presented by one of the attendees and then shared by Sharon Cox, BSN, MSN during the opening session, titled “Nurse Managers: Adding Value in a Time of Volatility.”

During one of the preconference workshops, a discussion about staff recognition had begun, when one attendee (I wish I knew her name to give credit where credit is due) shared a means of recognizing staff members that has had positive results. Rather than recognizing a staff member with a pat on the back or a letter of recognition to be filed, this manager asks the staff member (and I’m paraphrasing here), “I’d like to let someone important to you know what a valuable asset you are to us. To whom could I send your letter of recognition?”  She then wrote a personal note to to the person selected. 

This manager said she’s written to parents, spouses, mentors, and children of her staff members and has gotten positive feedback from all involved. She even met one staff member’s parents at a wedding and was thanked in person for the note she had written about their daughter.  

What a great idea!

It was my sophomore year of college and we were heading into the hospital for the first time. We had been learning about communication and practicing with one another and now it was time to meet a REAL LIVE patient and use our skills. I was so nervous!

I realize now what this first encounter meant to me. I wanted my first official interaction with a patient to be a positive experience. I had already had some doubts about nursing as a career choice (you can read a little about that in Is Nursing Really For Me?) and thought that this experience would give me some insight if this path was indeed the right one for me.

Another thing that I realize now, was that I wouldn’t be just talking as a friend, daughter, sister, or student – roles that I was familiar with. This was new territory and this patient would look to me for answers and support. My role as a nurse was beginning and this patient would trust me to say and do the right thing. 

Despite my nerves, I remember wondering (and being a little impatient about) why we weren’t doing real nursing things when we went to the hospital. I know now that communicating with patients is real nursing. Making that human connection is a big part of what makes us different from other disciplines in health care. Think about how you communicate with patients, their family members and caregivers, and other healthcare providers. Think about how others communicate with you? Any differences?

I like to think that since becoming a nurse, I’ve become a better communicator. I try to consistently think before speaking. I work hard to really listen to others rather than thinking about what I’ll say next when someone else is talking to me. When a difficult conversation is taking place, I think back to the communication strategies that I learned during those first years of nursing school. I also try to pay attention to my own nonverbal cues and those of others.

Have your communication skills and strategies changes since becoming a nurse? How so?

Each week we select 3 articles to feature on our Recommended Reading list. We rotate the items on this list so there are always 10 articles available – and they are all free to read! It’s fun for me to choose these articles for several reasons – first, I get to do a lot of reading, but most of all, because I do think about what I’m “hearing” here on our blog, out there on our social media pages, and in real-life discussions with my nursing friends, when I select the articles to include each week. We also select 3 continuing education articles to include on our Recommended CE list, and remember, all of our CE articles can be read online free!

A hot topic lately, and one that is dear to me, is communication. Interactions with both patients and our colleagues are so important for outcomes and patient and staff satisfaction. We know that patients trust us, we know that we know our patients well, and we know that we are important members of the healthcare team. One of our current featured articles, Facilitating Goals-of-Care Discussions for Patients With Life-Limiting Disease—Communication Strategies for Nurses, has a great section with the heading Nurses' Special Relationship With Patients: 

“For those with a life-limiting illness, nurses are the "constant" in their journey through a frequently fragmented healthcare system. The nurse becomes familiar with the patient's medical history, health status changes, "behind the scenes" discussions of the team, family dynamics, and expressions of thoughts, concerns, and values. Thoughtful communication is essential throughout the trajectory. As the nurse builds a relationship based on trust and consistency, he/she may be viewed as "more approachable" than others in the healthcare team and, as a consequence, be part of informal discussions with patients and families. Therefore, the nurse is well positioned to facilitate discussions focused on goals of care and treatment choices in the setting of a progressive debilitating illness.”

We do have special relationships with our patients. They are relationships that allow us into patients' lives during critical times, they are relationships that allow us to advocate for our patients, and they are relationships that allow us to provide the best possible nursing care to our patients. I hope you enjoy this article and the others on our Recommended Reading lists! 

Happy Reading 

Reference

Peereboom, K., & Coyle, N. (2012). Facilitating Goals-of-Care Discussions for Patients With Life-Limiting Disease—Communication Strategies for Nurses. Journal of Hospice and Palliative Nursing, 14(4). 

It’s been 2 weeks since I attended Nursing2012 Symposium and I am finally organizing all my notes! My pencil was giving off sparks as I tried to keep track of all that I was learning from the experts during the conference. What a great time I had learning, connecting with nurses (old friends and new!), and answering questions and sharing our ‘goodies’ in the NursingCenter booth in the exhibit hall. Of course, being in Orlando during some glorious weather also added to a wonderful getaway!

The opening address – Livin’, Laughin’, and Learnin’ through the Years – was presented by Barb Bancroft, RN, PNP, MSN. That title sums it up perfectly! The audience was laughing out loud as changes in nursing and medicine from the last 30 years were highlighted. I had forgotten just how many times classifications for diabetes have changed and was reminded of the funny things that patients sometimes say. Ms. Bancroft also shared her 8 ‘best bets’ in nursing. My favorites were “Never stop being a student” and “Work well with others.” 

Steve L. Robbins, PhD., presented the Keynote Address, entitled Unintentional Intolerance. This was powerful! In his presentation, Dr. Robbins used various exercises to demonstrate to the audience how we all have ‘gut reactions,’ and that the important thing is how we handle them. I wish I could demonstrate these exercises here via this blog post (I did use them on my family!). It was incredible – his discussion included topics such as cognitive scripts (how mindlessness and multiple remnant messages lead to this ‘unintentional intolerance’), drive-by greetings (we all do it…say “Hi. How are you?” without actually hearing the response), branding, and mindlessness (think of the things we do without thinking about them, for example, showering and then wondering “Did I wash my hair?”) The best quote that I took away from Dr. Robbins was “Leverage human differences to solve complex problems.”

In Your Patients at Risk: Preventing Complications, I was thrilled to listen to a former colleague of mine present! JoAnne Phillips, MSN, RN, CCRN talked about patient safety and nine adverse events that all hospitals should be working on: falls, ventilator-associated pneumonia, adverse drug events, central line-associated blood stream infections, catheter-associated urinary tract infections, pressure ulcers, obstetrical adverse events, surgical site infections, and venous thromboembolism. Ms. Phillips shared some great resources, namely Partnerships for Patients and the IHI Improvement Map. She also reminded us that “Patient safety is not about decreasing errors, it’s about decreasing harm.”

The next session that I attended was Stop the Revolving Door. Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC discussed the importance of “shifting the healthcare paradigm from a volume-based system to a value based system.”  Ms. Woods stressed 3 things to help reduce the numbers of ICU bounce-backs and hospital readmissions: better care, better communication, and better follow-up. Other points that stayed with me since her presentation include using ‘teach back’ in patient education, scheduling follow-up appointments prior to discharge, and tuning into noncompliance, meaning if a patient is noncompliant, we need to find out why. 

In Faculty-Guided Poster Tour: Ask the Experts, three experts – Frank Myers, MA, CIC; Cheryl Dumont, PhD, RN; and Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC – led an informal tour of the posters being presented at the conference. They pointed out key features of the posters themselves as well as the research being presented. Here are some of the things that I learned and I hope that you find them useful too! 

Linda Laskowski-Jones, MS, RN, ACNS-BC, CEN, FAWM and Captain Jeffrey R. Evans, BS, NREMT-P shared patient scenarios and the hospital and police responses in Bad Boys, Bad Boys…Whatcha Gonna Do? I learned a lot from these experts including never touching a weapon whether it’s immediately apparent or perhaps falls out when cutting off a trauma patient’s clothes, not using cell phones around suspicious packages (did you know they can detonate bombs?), and the importance of being aware of active gangs in your area. The most important advice I remember was always maintaining "situational awareness."

That’s just a sampling of the many presentations offered this year at Nursing2012 Symposium. All of the presentations were recorded and can be found at Lippincott’s eConference Center.com. If you have the opportunity to attend in the coming years, go for it! Maybe I’ll see you there!

End-of-life (EOL) care has always been a special interest of mine. I know the frustrations that often arise with EOL care in a critical care unit – for example, when a patient can no longer make decisions for himself and his family is unsure of his wishes, or when family members disagree. However, I also know how satisfying it can be when a patient’s death is a positive experience for all involved. Sometimes providing end-of-life care is just as rewarding as seeing a patient ‘turn the corner’ and get better. I imagine that some nurses find that EOL care is even more rewarding. 

When I read Ethics in Critical Care: Twenty Years Since Cruzan and the Patient Self-Determination Act: Opportunities for Improving Care at the End of Life in Critical Care Settings, I was reminded that while challenges continue, we actually have come pretty far with regards to advance care planning (ACP) and EOL care. Resources such as the Center for Practical Bioethics’ Caring Conversations, Respecting Your Choices, and Five Wishes have emerged to help patients and families discuss their wishes with one another. Other highlights of progress include The Joint Commission standards on palliative care, advance care planning, and pain management; National Healthcare Decisions Day (April 16); palliative care consultation services at large numbers of hospitals; and increased numbers of people with advanced directives. I encourage you to read this article in its entirety to see the extensive list of examples provided by the authors. 

What issues remain? 

• Advance care planning – increasing the number of patients with advance directives; living wills & power of attorney issues
• Caring for patients who are in a minimally conscious state vs. persistent vegetative state
• Providing hydration and nutrition
• Communicating a patient's wishes or plan of care during transfer from one care setting to another (for example, from nursing home to hospital)

Take some time to read this article (it’s free to read online while on our Recommended Reading list!). On page 103 (page 5 of the pdf), you’ll find 'Ten Things Critical Care Nurses Can Do To Improve Advance Care Planning.' 

Reference: 

Rushton, C., Kaylor, B., & Christopher, M. (2012). Ethics in Critical Care:Twenty Years Since Cruzan and the Patient Self-Determination Act: Opportunities for Improving Care at the End of Life in Critical Care Settings. AACN Advanced Critical Care, 23(1).