The fundamental nature of the aspect of relaying accurate information from one health provider to another to meet quality and safety goals during handoffs has always intrigued me. In my understanding, a handoff (also known as a sign-out, a handover, or a shift report) is the act of transferring and accepting responsibility of caring for a patient from one health caregiver to another through effective communication (Friend et al., 2018, p. 1169). The skill of adequately performing handovers first captured my interest at an early age when I witnessed fast hand the high consequences of failure during handoffs. Later on, my interest on correct performance of handoffs was lifted a notch higher when I read about the 1995 case of the amputation of a wrong leg belonging to Willie King in Tampa because of the improperly conveyed information during a handoff (Feraco et al., 2016, p. 524). Moreover, my curiosity and concern about the proper performance of handoff was further amplified by the reports that indicated that problems arising during handoffs were the leading causes of malpractice in SA’s insurance agency, and that in Australia, 11% of the adverse events that led to permanent disability were caused by communication failure during handoffs. Therefore, in this reflective account essay, I will be using the Driscoll (1994) model of reflection to demonstrate my learning and emerging confidence in the practicing of the handoff skill as I relate between my theoretical knowledge and practice.
Evidently, the proper performance of a handoff is a crucial nursing skill as handoffs are performed regularly during patient care, especially during times when there needs to be changes in nursing shifts updates. In my opinion, handoffs are a high point of vulnerability as the person accepting the responsibility of caring for a patient always has a fresh perspective, which increases the chances of the occurrence of fixation error (Davis et al., 2016, p. 146). My opinion originates from the conclusion I came up with after witnessing an incident that occurred in a handoff that I participated in that left an unerasable mark in my memory. The incident occurred during one evening when I (as a nursing student) accompanied a team of night float residents to an evening sign-out after a long shift. The handover, which was characterized by work and talk, occurred at the resident lounge, and it involved about 50 residents describing all the patients in their lists to the night float team of residents (Militello et al., 2018, p. 495).
During the handoff, I was working closely with Mercy (not her real name), a resident nurse, who seemed quite distracted by personal issues during the entire handoff process. The handoff that covered the 50 current inpatients took about 45 minutes. That evening, I remember witnessing Ms. Tiffany (not her real name), a 65-year-old female, who was in her fourth day after undergoing colossal reversal start experiencing short breath and tachycardia with a SpO2 of 89% (Lescinskas et al., 2018, p. 698). Mercy, who was Ms.Tiffany’s primary caregiver, took hold of the patient’s situation, but could not recall anything special about her or any of her specific details that were discussed during the handover. The inability to recall much information about Ms. Tiffany caused Mercy to take much time reviewing her history on the hospital’s electronic medical record system and evaluating the patient physically. A considerable amount of time passed before Mercy realized that Ms. Tiffany had a history of congestive heart failure for which she took diuretics daily while at home, after which she noted that the daily diuretics had not been prescribed to Ms. Tiffany as an inpatient. The time that elapsed before Mercy completely understood her patient’s situation was quite long to the extent of causing the patient’s condition to escalate and become extremely critical. A CXR that would have demonstrated pulmonary edema and a Lasix would have improved Ms. Tiffany’s condition (Cooper et al., 2017, p. 9). However, because of Mercy’s negligence and distraction during the handoff, that was not the case.
In as much as I was working closely with Mercy, there was nothing much I could do to stop her from compromising the patient’s health since I felt limited by my position as a student nurse. I was completely infuriated by Mercy’s level of negligence and ignorance. I could not comprehend why she had to be preoccupied with her personal issues instead of paying attention to the information being passed to her during the handover (Patel and Landrigan, 2019. I feel that I was partly to blame and that I was partially responsible for Ms. Tiffany’s worsened condition at the time because I should have asked her to avoid being distracted by her phone.
Moreover, I should have told given her the information that I had regarding the patient’s history. However, fear not only held me back, but it also caused me to tongue-tied. Being a junior, I felt that I was not in a position to correct my senior or pass such critical information to a senior. I wanted her to confirm the patient’s history in order to make the correct diagnosis and have a more knowledgeable plan of action regarding the patient’s treatment (Colvin est al., 2016, p. 56). After that incident, I not only felt that I failed as a health care provider, but I also felt that I failed in my human responsibility towards my fellow human beings. In fact, upon witnessing how the patient suffered when her condition became critical, I was filled with both compassion and anger; I was compassionate with the patient and angry at both Mercy and me, and honestly, at that time, I wished someone would punish Mercy and me heavily for our mishap.
Since that fateful incident, I have always regarded handoffs as high-risk events. Additionally, I resolved that during my practice as a nurse whenever I engage in handoffs, I should always strive to beware of significant data or events regarding the current inpatients, which will always prepare me to deal with impacts that may arise from previous events (Higgins et al., 2017, p. 88). I also resolved always to anticipate future events and equip myself with knowledge essential in performing nursing tasks (Wears et al., 2016, p. 192). Notably, the incident taught to me to not only avoid dropping or reworking progressing activities, especially the ones that are team-based but also to avoid shifting goals, priorities, plans, or decisions (Alfes and Reimer, 2016, p. 215). I believe that the most important lesson that I learned from the incident was the importance of quality communication for an effective and proper handoff. For communication to be termed as quality, it has to involve the full participation of the parties involved.
Alfes, C.M. and Reimer, A., 2016. Joint training simulation exercises: Missed elements in prehospital patient handoffs. Clinical Simulation in Nursing, 12(6), pp.215-218.
Colvin, M.O., Eisen, L.A. and Gong, M.N., 2016, February. Improving the patient handoff process in the intensive care unit: keys to reducing errors and improving outcomes. In Seminars in respiratory and critical care medicine (Vol. 37, No. 01, pp. 096-106). Thieme Medical Publishers.
Cooper, A.Z., Schaffernocker, T. and McCallister, J., 2017. Educational Handoffs from Medical School to Residency: an Emerging Opportunity. MedEdPublish, 6.
Davis, R., Davis, J., Berg, K., Berg, D., Morgan, C.J., Russo, S. and Riesenberg, L.A., 2018. Patient Handoff Education: Are Medical Schools Catching Up?. American Journal of Medical Quality, 33(2), pp.140-146.
Feraco, A.M., Starmer, A.J., Sectish, T.C., Spector, N.D., West, D.C. and Landrigan, C.P., 2016. Reliability of verbal handoff assessment and handoff quality before and after implementation of a resident handoff bundle. Academic pediatrics, 16(6), pp.524-531.
Friend, K., Hook, L. and Joshi, A.R., 2018. Improving Information Transfer during Transitions of Care via Standardized Handoffs. The American Surgeon, 84(7), pp.1169-1174.
Higgins, A., Brannen, M.L., Heiman, H.L. and Adler, M.D., 2017. Patient handoffs: is cross cover or night shift better?. Journal of patient safety, 13(2), pp.88-92.
Lescinskas, E., Stewart, D. and Shah, C., 2018. Improving handoffs: Implementing a training program for incoming internal medicine residents. Journal of graduate medical education, 10(6), pp.698-701.
Militello, L.G., Rattray, N.A., Flanagan, M.E., Franks, Z., Rehman, S., Gordon, H.S., Barach, P. and Frankel, R.M., 2018. “Workin’on Our Night Moves”: How Residents Prepare for Shift Handoffs. The Joint Commission Journal on Quality and Patient Safety, 44(8), pp.485-493.
Patel, S.J. and Landrigan, C.P., 2019. Communication at Transitions of Care. Pediatric Clinics.
Wears, R.L., Perry, S.J. and Patterson, E.S., 2016. Handoffs and Transitions of Care. In Handbook of Human Factors and Ergonomics in Health Care and Patient Safety (pp. 192-201). CRC Press.