Nursing Quality and Safety Improvement

This assignment delves into the critical aspects of quality and safety within nursing practice. It examines influential articles that shed light on diverse interventions aimed at reducing acute care transfers, enhancing the role of healthcare information technology, addressing nurse burnout, and promoting a competency-based approach to quality improvement. Furthermore, the assignment considers public health nursing's contribution to population-centered healthcare.

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
NURS2006 ASSIGNMENT 3
Clinical Practice Improvement Project Report
Student Name, FAN and ID:
Project Title:
Clinical Handover Communication using Patient Intervention Comparison (PICO)
Project Aim:
 To explore whether using ISOBAR technique for clinical handovers as compared to general verbal
technique can help in reducing the percentage of clinical errors in health care settings.
Relevance of Clinical Governance to your project
Clinical governance refers to the framework and criteria employed by the NHS organizations to improve the
quality of services offered as well as safeguarding the high standards in medical care through the creation of
excellence environment for clinical healthcare. Clinical government is not only limited to the NHS organizations
but also entails a practice management and integrated principles which are used in successful dentistry. Clinical
handovers mechanisms were introduced in order to reduce the probability of the clinical errors in the medical
settings, however in most cases, the concept of clinical handovers are not complied with in an optimal manner
(Black et al., 2015). There are many prevalent challenges or issues in the clinical setting involving inadequate
usage of clinical handovers, a few key challenges in this situation are:
One of the key issues that have identified in this scenario had been the alarming rate of negative consequences

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
in the care planning and execution for the patients for the lack of proper communication during shift
handovers. According to the Boswell et al., 2015, one of the most important factors associated with nursing
handovers is the fact that it contains key information regarding the condition of the patient and what principle
measures are to be taken while handling that particular patient. In cases where the nursing handover
guidelines are not followed properly, the care standards and quality suffers. Elaborating more, the nursing
handovers are of crucial importance in the scenarios where the patients need to be relocated to different
wards in critical conditions, in situations where the nursing handovers do not contain enough information; the
medical complications of the patients have been seen to deteriorate to even life threatening conditions. Hence,
not adhering to handover protocols is a direct indication of compromised clinical performance standards
(Johnson et al. 2014).
Considering the clinical standards, there are different practices for clinical handover followed, while in some
cases bedside handovers are a protocol, in some scenarios the method of informal verbal handovers is
followed extensively. However, the verbal handover technique is not just informal but is constitutes chances of
major clinical errors. According to the detailed study by authors, it has been discovered that the verbal mode of
nursing handovers are extremely inadequate to relay detailed information about the condition of the patient to
the attending nurses. Along with that another major concept is the fact that conveying information about the
patient cannot complete the authenticity and reliability of a bedside documented nursing handover (Boswell
et al., 2015).
Environmental Safety for Staff, Patient and Public is also another essential governance policy which one needs
to evaluate in clinical practice and implementation. In fact, the policy outlines that patients have an equal right
to clean as well as safe treatment all the time. The system is essential in building the confidence of patients as
they receive health care by outlining the set procedures at designated stages in nursing. Thus, Health and

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
Safety at Work Act 1974 form the fundamental grounds for keeping patients safe in the hospital while at the
same time helps in protecting workers. Therefore, the policy aims at setting out the responsibilities which the
employer has towards both the employees and public as a whole. Additionally, the act also encourages
companies in examining workplace risks as well as in coming up with measures of addressing the challenges in
return (Mikkonen et al., 2016 p.187).
Fair and manageable care is another key theme which governs clinical care practices. This aims at provide
prompt healthcare services as well as gives patients access to treatment. Fair and manageable care is governed
by Human Rights Act of 1998, Race Relations and its Amendment Act (2000) and Infirmity Discernment Act
1995. In essence, the Race Relations Act enhances equity and good mutual relations among people of distinct
groups. This includes having access to services to help patients of various ethnicities to make utilization of and
completely comprehend the neighbourhood dental administrations accessible. The Human Rights Act covers a
scope of political and social equality and the Disability separation act makes it unlawful to oppress a man on
the grounds of handicap in the range of business, offices, and administration. An entrance review ought to be
done by an outsider to survey current consistency under this demonstration and to acquaint enhancements in
access with debilitated patients.
Considering the scope for professional development and management, the issues prevalent in this sector due
to improper usage of clinical handovers are many. First and foremost it has to be mentioned nursing is a
profession that is absolutely evidence based. And there are many instances where the nursing professionals
have to take reasonable clinical decisions where the patients are in need of immediate nursing interventions in
critical conditions. These activities do not only broaden the scope of practice for the nursing individual, but also
contributes to their professional growth and enhances their ability to handle critical patients. However, these
emergency decisions are very crucial, and a single error can cost the patient severely and even lead to

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
penalizing consequences for the nursing professional as well (Clarke and Persaud 2011). According to the Elwyn
et al. 2013, the information in the nursing handover is crucial for the shift change nurse to understand the basic
care needs of the patients and a general idea of the condition that the patient is in, in case t6hat information is
relayed is an inadequate manner, the concept of correct patient assessment and care planning is disrupted. It
can also be stated in this context that the incomplete information provided to the nursing professional in the
handover can potentially misguide him or her leading to severe consequences. Which further narrows down
the scope for professional development of the nursing professional and rather imparts negative effect on the
career growth of the person (Elwyn et al. 2013).
Now considering the clinical risks associated with the chosen scenario, there are a multitude of different risks
that are prevalent in scenarios where the clinical handovers are either not optimal or are not followed as a
regular regime. It has to be understood that the data about the patients regarding vital signs, patient problem,
health status, allergic reactions, past medical history, medication charts and risk factors are stated with clarity.
In case of verbal handovers, it is impossible for the nursing professional to incorporate each and every intricate
detail while communicating with the shift change nurse. Hence, clinical errors like flawed medication
administration, hospital acquired infection, fall, allergic manifestations and even cardiac issues can arise.
Hence, there had been a need for a standardized technique of maintaining nursing handovers with a protocol
to strictly comply (Flemming and Hübner 2013).
Considering the government initiatives, there have been many steps taken to ensure optimal consumer value
while providing safe health care services, however, with the lack of an imperative guidelines or protocol to
maintain in handover system that incorporates the importance of traceability of clinical decisions made by the
nursing professional communicating the subjective issues of the patient clearly decreases the possibility of the

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
full story of the patient to be shared with the shift change nurse (Boswell et al., 2015).
Evidence that the issue/problem is worth solving:
From the literature search and evaluation, it can be stated that nursing handovers are a necessity, and the
nursing handovers should be integrative and detailed, utilized every time the patient is assessed by the nursing
professional. That is the reason a few government initiatives have been taken while considering the nursing
handover implementation. For instance, the first government initiative regrading standardizing nursing
handovers had been the “safe handover: safe patient’ scheme introduced by the British government in the year
of 2004 which had been closely followed by Australia and USA around 2007 in the effective “handoffs” scheme
(Klim et al. 2013).
Along with that it has to be mentioned that various patterns or frameworks have also been developed in
attempt to improve the reliability and authenticity of the nursing handovers. The impact of poor clinical
handover is an incapable framework, best case scenario and patient demise even under the least favourable
conditions and therapeutic blunders. Clinical handover is critical to guarantee coherence of patient care and
patient safety. It serves many capacities and there are many variables that influence clinical handover, and this
is why maintaining a standard framework or protocol while maintaining clinical handovers is extremely crucial
for providing safe and optimal care to the patient (Kerr et al. 2016).
ISoBAR is one of the most abundantly utilized framework for devising optimal clinical handovers which provides
the most scientific and logical tool for making nursing handovers as detailed as possible. It is a mnemonic
framework designed for the purpose of improving the patient safety and care quality. The ISoBAR technique or
framework has 5 different elements; the first element is identification, where the patient for whom the
handover is being prepared is identified (Stanhope and Lancaster 2015). The second section is situation, where

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
the medical complications that the patient is facing at the moment are explained in detail. The third section is
background which discusses the past medical history of the patient and the in the fourth section the
assessment data of the patient is mentioned in detail. Last section of the tool recommendation where the
nursing individual will note down any suggestive intervention which can prove to be helpful in helping the
patient overcome whatever health care related complication that has arisen (Graan et al. 2016).
ISOBAR technique is considered to be one of safest techniques for transfer of patent information, and in many
of the research studies have proved the efficiency of this tool in devising the nursing handovers that facilitate
optimal patient safety and care priorities (Sherwood and Barnsteiner 2017). Rushton et al. 2015 in their cohort
analysis study have used the ISOBAR technique for testing out the positive impact of this tool on the efficiency
of the bedside handovers and the results indicated that the combination of ISOBAR handovers with verbal
communication yielded the best results for reducing clinical errors and improving the patient safety. Hence, for
this project, the PDSA activity will also utilize the ISoBAR technique for exploring its impact on the percentage
of clinical errors.
The primary stakeholders:
Some of the key stakeholders which one needs to consider in clinical handover communication and
implementation include healthcare providers, payers, employers and patients. In fact, it is important to identify
the role of each of them before coming up with the framework. Additionally, social environment is also a
fundamental factor which one needs to examine while setting up the strategic plan for the implementation
process (Moran, Conrad and Burson, 2016).
CPI Tool:

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
Patient safety proposals in clinical practice and improvement are vital criteria and thus, must follow strict
procedures. This project adheres to the outlined procedures in the Human Service and Health Department of
March 2003.
PLAN: The very first activity in this [project will be to plan the entire procedure in a meti9culous manner to
ensure that the each and every detail of the planning procedure is taken into consideration. The very first
activity is to finalize the heath care setting on which the intervention technique will be carried out. For this
project, the health care setting chosen will be acute ward and the bedside handover maintained by the nursing
professionals will be strictly based on the ISoBAR template. All the enrolled ward nurses will participate on the
study and the project duration will be for two weeks. The data will be collected based on the parameters like,
percentage of reduction in the number of clinical errors per shift, the personal feedback from the patients and
patient family regarding the safety and quality of care provided, and lastly personal feedback from the nurses
regarding the ease in patient takeover during shift changes. Care should be taken to design a well articulated
action plan so that each and every parameter of the project is addressed (Lockwood 2016).
DO: the next section of the project will be designing a well articulated action plan so that each and every
parameter of the project is addressed. Care should be taken to inform the participants of the project and
consent is obtained before progressing with the project. All ethical requirements must also be strictly met
during the project taking attention so that the best interests of the patients are not compromised in any
manner.
STUDY: The next section of the project as guided by the CPI tool is studying the data collected and analysis of
the same data. There are many limitations in the study design that has the potential to introduce significant
bias, care should be taken to avoid selection bias as much as possible.

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
ACT: The last section is associated with documenting project plan and its outcome, it has to be understood that
the purpose behind this project had been to explore the benefits of using ISoBAR technique for maintaining
bedside handovers while shift change or patient takeover. This project is an excellent tool in determining the
extent of positive changes it can bring to the care safety and quality and the possible reduction in the clinical
errors. Hence the subjective data gathered and analysis will be documented on this step with a explanative
detailed discussion exploring the outcome and arriving at a possible verdict.
Summary of proposed interventions:
Nursing handover is one of the techniques implemented in the scenario of health acre ease the process of
patient takeover and minimise the chances of clinical errors happening due to flawed conveying of subjective
and objective data regarding the patients. However verbal handover techniques fail to serve the purpose of
safe and authentic transfer of informational data. Hence, there is need for a standardized protocol being used
in this scenario so that each and every intricate detail of the patient can be documented and provided to the
nurse to whom the patient is being transferred to be cared for (Ouslander et al. 2014). ISoBAR technique is a
detailed framework which incorporates all the necessary elements to make the nursing handovers scientific,
detailed and reliable. And this intervention technique will be extremely helpful in minimising the percentage of
clinical errors that are a direct result of miscommunication of patient information (Piscotty, Kalisch and Gracey‐
Thomas 2015).
Barriers to implementation and sustaining change:
The obstacles to the critical practices implementations as well as supporting changes mainly summarized
below:
Time constraint: The project required an extensive period of time and effort being invested.

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
Budget: Maintaining a strict ISoBAR format for each and every patient for all shifts will require a strong budget
being employed for the project.
Reluctance: Reluctance or lack of compliance in the nursing staff regarding the new technique implemented for
handovers has been a significant conflict to overcome.
Evaluation of the project:
The assessment process for this project mainly summarized as posed in the following steps
Identification of the key parameters of decreasing clinical errors in the hospital using ISoBAR
approach. Secondly, it is important to evaluate and ascertain all the necessary risks and benefits
associated with project. Thirdly, excitations of the effectiveness of the entire project have to be
determined and established. Fourthly, it is also essential to design and evaluate all the utility
values and cost effective of the process. Fifthly, intervention approach to all the resulting and
emerging issues must be determined and established. Finally, it is important to examine the net
cost and healthcare costs connected to adverse events in the clinical implication practices.

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
References:
Black, A.T., Balneaves, L.G., Garossino, C., Puyat, J.H. and Qian, H., 2015. Promoting evidence-
based practice through a research training program for point-of-care clinicians. The Journal of
nursing administration, 45(1), p.14. Retrieved
from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4263611/
Book.
+Elsevier+Health+Sciences.&ots=g9nS3v3h1Q&sig=XO0l8EdN1Y37_pDy8nQ5NlLMvVo#v=onepa
ge&q&f=false
Boswell, J.F., Kraus, D.R., Miller, S.D. and Lambert, M.J., 2015. Implementing routine outcome
monitoring in clinical practice: Benefits, challenges, and solutions. Psychotherapy
research, 25(1), pp.6-19. Retrieved
from:http://www.tandfonline.com/doi/abs/10.1080/10503307.2013.817696
Clarke, C.M. and Persaud, D.D., 2011. Leading clinical handover improvement: a change
strategy to implement best practices in the acute care setting. Journal of patient safety, 7(1),
pp.11-18. Retrieved
from:http://journals.lww.com/journalpatientsafety/Abstract/2011/03000/
Leading_Clinical_Handover_Improvement__A_Change.3.aspx
Elwyn, G., Scholl, I., Tietbohl, C., Mann, M., Edwards, A.G., Clay, C., Légaré, F., van der Weijden,
T., Lewis, C.L., Wexler, R.M. and Frosch, D.L., 2013. “Many miles to go…”: a systematic review of

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
the implementation of patient decision support interventions into routine clinical practice. BMC
medical informatics and decision making, 13(2), p.S14. Retrieved
from:https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/1472-6947-13-S2-
S14
Flemming, D. and Hübner, U., 2013. How to improve change of shift handovers and
collaborative grounding and what role does the electronic patient record system play? Results
of a systematic literature review. International journal of medical informatics, 82(7), pp.580-
592. Retrieved from: http://www.sciencedirect.com/science/article/pii/S1386505613000622
Graan, S.M., Botti, M., Wood, B. and Redley, B., 2016. Nursing handover from ICU to cardiac
ward: Standardised tools to reduce safety risks. Australian Critical Care, 29(3), pp.165-171. DOI:
10.1016/j.aucc.2015.09.002
Johnson, M., Sanchez, P., Suominen, H., Basilakis, J., Dawson, L., Kelly, B. and Hanlen, L., 2014.
Comparing nursing handover and documentation: forming one set of patient information.
International nursing review, 61(1), pp.73-81. DOI: 10.1111/inr.12072
Kerr, D., Klim, S., Kelly, A.M. and McCann, T., 2016. Impact of a modified nursing handover
model for improving nursing care and documentation in the emergency department: A pre and‐
post implementation study.‐ International journal of nursing practice, 22(1), pp.89-97. DOI:
10.1111/jocn.12274

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
Kerr, D., McKay, K., Klim, S., Kelly, A.M. and McCann, T., 2014. Attitudes of emergency
department patients about handover at the bedside. Journal of clinical nursing, 23(11-12),
pp.1685-1693. Retrieved from: http://onlinelibrary.wiley.com/doi/10.1111/jocn.12308/full
Klim, S., Kelly, A.M., Kerr, D., Wood, S. and McCann, T., 2013. Developing a framework for
nursing handover in the emergency department: an individualised and systematic
approach. Journal of clinical nursing, 22(15-16), pp.2233-2243. DOI: 10.1111/ijn.12365
Lockwood, C., 2016. What is the best nursing handover style to ensure continuity of
information for hospital patients?. International journal of nursing studies, 58, pp.97-99. DOI:
http://dx.doi.org/10.1016/j.ijnurstu.2016.03.004
Melnyk, B.M., Gallagher Ford, L., Long, L.E. and Fineout Overholt, E., 2014. The establishment‐ ‐
of evidence based practice competencies for practicing registered nurses and advanced‐
practice nurses in real world clinical settings: proficiencies to improve healthcare quality,‐
reliability, patient outcomes, and costs. Worldviews on Evidence Based Nursing‐ , 11(1), pp.5-15.
Retrieved from: http://onlinelibrary.wiley.com/doi/10.1111/wvn.12021/full
Mikkonen, K., Elo, S., Kuivila, H.M., Tuomikoski, A.M. and Kääriäinen, M., 2016. Culturally and
linguistically diverse healthcare students’ experiences of learning in a clinical environment: a
systematic review of qualitative studies. International journal of nursing studies, 54, pp.173-
187. Retrieved from: http://www.sciencedirect.com/science/article/pii/S0020748915001984

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
Moran, K.J., Conrad, D. and Burson, R., 2016. The doctor of nursing practice scholarly project.
Jones & Bartlett Publishers. Retrieved from:https://books.google.co.in/books?
hl=en&lr=&id=kqDOCwAAQBAJ&oi=fnd&pg=PP1&dq=Moran,+K.J.,+Conrad,+D.+and+Burson,
+R.,+2016.+The+doctor+of+nursing+practice+scholarly+project.+Jones+
%26+Bartlett+Publishers.
+&ots=S2aw2L7QIL&sig=h5KWz7AW1Ku2_2OFP3SXG0fSiAI#v=onepage&q&f=false
Ouslander, J.G., Bonner, A., Herndon, L. and Shutes, J., 2014. The Interventions to Reduce Acute
Care Transfers (INTERACT) quality improvement program: An overview for medical directors
and primary care clinicians in long term care. Journal of the American Medical Directors
Association, 15(3), pp.162-170. Retrieved
from:http://www.sciencedirect.com/science/article/pii/S1525861013006907
Piscotty, R.J., Kalisch, B. and Gracey Thomas, A., 2015. Impact of healthcare information‐
technology on nursing practice. Journal of Nursing Scholarship, 47(4), pp.287-293. Retrieved
from: http://onlinelibrary.wiley.com/doi/10.1111/jnu.12138/full
Rushton, C.H., Batcheller, J., Schroeder, K. and Donohue, P., 2015. Burnout and resilience
among nurses practicing in high-intensity settings. American Journal of Critical Care, 24(5),
pp.412-420. Retrieved from: http://ajcc.aacnjournals.org/content/24/5/412.short
Sherwood, G. and Barnsteiner, J. eds., 2017. Quality and safety in nursing: A competency
approach to improving outcomes. John Wiley & Sons. Retrieved from:

CLINICAL PRACTICE IMPROVEMENT PROJECT PAGE \*
MERGEFORMAT 13
https://books.google.co.in/books?
hl=en&lr=&id=zToODgAAQBAJ&oi=fnd&pg=PR3&dq=Sherwood,+G.+and+Barnsteiner,+J.+eds.,
+2017.+Quality+and+safety+in+nursing:+A+competency+approach+to+improving+outcomes.
+John+Wiley+%26+Sons.
+&ots=x77bfATHL3&sig=qWR4iDfBFNwZ0dNUaZ_a9zhKPZY#v=onepage&q&f=false
Stanhope, M. and Lancaster, J., 2015. Public Health Nursing-E-Book: Population-Centered Health
Care in the Community. Elsevier Health Sciences. Retrieved
from:https://books.google.co.in/books?
hl=en&lr=&id=mvWQCgAAQBAJ&oi=fnd&pg=PP1&dq=Stanhope,+M.+and+Lancaster,+J.,
+2015.+Public+Health+Nursing-E-Book:+Population-
Centered+Health+Care+in+the+Community.+Elsevier+Health+Sciences.
+&ots=SYexHDre8O&sig=MRMW7s4OmbFRR-WJjWCdkQXIa9A#v=onepage&q=Stanhope%2C
%20M.%20and%20Lancaster%2C%20J.%2C%202015.%20Public%20Health%20Nursing-E-Book
%3A%20Population-Centered%20Health%20Care%20in%20the%20Community.%20Elsevier
%20Health%20Sciences.&f=false