IMPROVING COMMUNICATION IN HANDOVER AND REFERRAL USING A NURSE-LED QUALITY IMPROVEMENT INITIATIVE (2018)

Paul Froilan U. Garma, MAN, RN, RM; Sheri Anne Maximille Cabañes, RN;
Niño Valentino Delgado, RN; 
Maria Keziah Legion, RN; Alyssa Jenny Tupaz, MAN, RN; 
Melanie Salido, RN; Nicanor Alfaro, RN

 

Nursing Services, Department of Medicine, University of the Philippines Manila
Philippine General Hospital

 

Background of the Study

Effective communication is integral in collaboration and teamwork in healthcare settings in order to maximize patient health outcomes. The relay of critical information regarding patient’s health status or clinical issues during nurse’s handover or multidisciplinary referral should be accurate, complete and timely. The nurse-led quality improvement initiative termed as IM FAIR (ISBAR Method: Format, Application and Instruction for Referral) bridges the gaps in communication pathway in an interprofessional and multidisciplinary environment using the ISBAR (Identify, Situation, Background, Assessment and Recommendation) model.

 

Objective

This project aimed to structure the way nurses relay critical clinical information during handover or referral to other members of the healthcare team using ISBAR.

 

Methods

This is a quality improvement initiative. The four-month project, referred to as IM FAIR, was anchored on Kurt Lewin’s three-stage change process namely unfreezing, change and refreezing. In the unfreezing phase, consultative meeting focusing on needs assessment and problem identification was done. Competency enhancement activities such as series of workshop that was applied for continuing professional education units, case completion in nurse’s handover and referral and one-on-one mentoring and integration of the project in the clinical unit constituted the change phase. Flyers, infographics and worksheets for cases were utilized. A scoring rubric on the salient indicators of ISBAR as well as a built-in Excel tracker was developed in evaluating the competencies of nurses in using ISBAR based from the cases submitted. Lastly, the refreezing phase comprised of program reinforcement strategies such as spot-checking and dialectic evaluation from the perspectives of nurses and physicians. Dialogue on transforming the project into unit policy is on-going.

 

Results

Fifty-six nurses from the medical intensive care unit, general medical wards and dialysis unit participated in the project. Majority are females (87.5%), bedside nurses (77 %), with a mean age of 38 years (SD= 9.80, range 23-60), and average hospital work experience of 10 years (SD= 8.06). Nurses demonstrated satisfactorily in meeting the indicators of ISBAR with an over-all rating of 84.54%.  This project which structured the communication process improved the perceptions of doctors and nurses on collaborative practice and effective delivery of care. Themes that emerged during the project evaluation include promotion of collaborative and autonomous nursing practice, comprehensive patient assessment, and effective, efficient and timely delivery of care. Administrative issues such as increased patient workload/understaffing, stressful and resource-constrained work environment and insufficient time are threats identified that may hinder the full utilization of ISBAR.

The challenge is to ensure that the innovation becomes well integrated in the clinical practice of nurses. Further, it is recommended that the impact of the project be examined in the light of patient and nurse-sensitive outcomes.