Improving Shift Handovers in ICU: A Critical Review and Action Plan

This paper critically reviews the procedure of shift handovers in ICU and proposes an action plan for improvement based on evidence-based approach. The problem of ineffective shift handovers is identified and the rationale for improvement is discussed. A standard setting statement is drafted and details for the implementation of the plan are discussed. The subject is nursing, and the course code, course name, and college/university are not mentioned.

Running head: NURSING
Nursing
Name of student:
Name of university:
Author note:

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Introduction
Healthcare settings are responsible for delivering best possible services to the
healthcare consumers to achieve better outcomes within a stipulated time. Professionals
working in collaboration with each other in different settings are to demonstrate suitable
professional skills and competencies to engage in safe practice. It is to be remembered that the
care setting is accountable for putting in place the varied policies for clinical practice as per the
best interests of the patient population. In this regard it is crucial that changes are implemented
in practice to augment the policies or procedures adhered to. Action plans are to be articulated
based on research evidence that can guide positive changes in different areas of practice within
the different wards. These are to be then implemented in consultation with all stakeholders and
a thorough evaluation is also warranted for understanding the effectiveness of the same. The
present paper reports on handovers of shift duty as the chosen area of practice in the current
ward of ICU at a reputed healthcare setting at Riyadh, Saudi Arabia and critically reviews its
procedure. Based on evidence based approach, an action plan is drawn up on how the practice
can be better improved. The report identifies the problem in the clinical area and gives a
rationale for improvement on the basis of relevant literature. A standard setting statement is
drafted in this regard. Details for the implementation of the plan are discussed including how the
standard would be communicated to others and the method of evaluation of the standard set. A
conclusion is provided at the end of the paper to summarize key points.
Problem identified in clinical area
Delivery of appropriate and safe health care is at the core of the services provided at the
present ICU at the Riyadh hospital. The ICU is the specialized department that focuses on
providing intensive treatment to the patient population. The professionals working at the unit are
accountable for catering to the needs of individuals suffering from life threatening diseases and
illness. Patients require close monitoring and constant support provided in a professional
manner by skilled workers (Haniffa et al., 2017). The ward is distinguished from other wards in
that the staff-to-patient ratio is higher and access to advanced equipment and resources is
enabled.
Shift handover is a common tradition among nursing professionals at the ward that has
drawn the attention at present in relation to need of betterment. Clinical handovers refer to the
transfer of accountability and professional responsibility of patient care aspects from one
professional or professional group to another on a temporary and permanent basis. The

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purpose of the handover is to make sure that professionals about to take in charge of care have
the required level of understanding of clinical priorities (Blais et al., 2015). At the present ward, a
number of concerns have been identified in relation to the procedure of shift handover. Though
it Is acknowledged that shift handover is essential and inevitable for shift working pattern, not
much have been done to ensure that the procedure for the same is robust. Clinical handovers
between shifts has remained a high risk activity at the setting for patient safety. Critical
information is not transferred in a correct and effect manner that maintains continuity of care.
Observations at the ICU indicated that shift handovers did not take place at a designated
area and at a particular time without interruptions. While some professionals considered
completing the handovers at the bedside, others did not consider so. At one instance it was
noticed that a nurse had used the office room for the handover. Handovers at places other than
the bedside are not effective as the professionals are not able to observe the patient and collect
updated patient information at the time of the handover (Malekzadeh et al., 2013). The staff
taking part in the handover has a crucial role in the process. The desired process model
encompasses staffs from all grades to be present (Graan et al., 2016). At the current ward the
handovers included only the incoming and outgoing nursing professional. The duration of the
handovers were also found to be differing to a considerable extent. While some handovers
lasted for 45 minutes, some were completed within 15-20 minutes. It is the best practice that
shift handovers are carried out without interruption so that optimal information is passed on
within a short time frame in an accurate manner. At the present ICU it was observed that
handovers were often disturbed and interrupted. Moreover, the proportion of urgent and non-
urgent distractions was nearly equal. Despite a guideline put in place for handover, there has
been non-adherence to the same. It is therefore significant to bring improvement in the standard
of shift handovers at the unit.
Rationale for improvement
The importance of shift handovers has been gaining recognition in the recent times
against the evolving healthcare needs of patient population. In the past, ICUs were only covered
by senior medical officers and experienced nursing professionals. In the more recent time, with
the advent of modern technologies and knowledge of medical science, ICUs have increasingly
become populated with junior physicians and nurses with lesser working experiences. It is
therefore crucial that appropriate guidelines are put in place so that the process of care delivery
is not impaired at any stage (Spooner et al., 2018).

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Shift handovers are the transfer of clinical issues pertaining to a patient that needs to be
known and the changes required in the treatment plan outlined after the responsibility of care
has been transferred from one professional to another. The intensive care unit handover is
perceived to be a core skill of the professionals working in it. For many professionals it has been
highlighted to be a stressful event of their regular practice (Zegers et al., 2016). Skills for
effective handovers are to be taught to professionals as a part of their formal education.
Nevertheless, the actual scope for developing the skills for handovers is gained during the daily
practice. As pointed out by Thomson et al., (2018) the main aim of shift handover is provision of
a high quality care. Nevertheless, communication of poor information at the time of handover
endangers safety of the patient. A rich pool of evidence points out that ineffective shift
handovers are responsible for medication errors together with increase of risks of sentinel
events. Further, the risks of delays in the course of treatment are witnessed that leads to
prolonged length of stay at hospital and decreased patient satisfaction. Effective communication
is an integral part of clinical handovers and has been referred as one of the most important
goals for patient safety. This entails that credible and up-to-date information is passed on that is
minimally disrupted.
Marshall et al., (2018) have brought into focus the benefits of appropriate ICU handover.
The most significant benefit is that safety of the patients is protected. Lapses when present in
handover lead to mistakes that are fatal for patients. The subsequent result is mortality and
morbidity. Poor handover also leads to inconsistency and fragmentation of care. If one is to
achieve greater continuity of care robust handover is to be undertaken. Increases service
satisfaction in the next benefit of proper handover. Patient’s perception and outlook of
competency and professionalism is improved and reaffirmed as a result of proper handover
communication. The researchers mentioned that timely diagnosis and investigations of health
problem presented by patients is possible when handover is accurate. This is a sign of
increased efficiency and improvement in service delivery of the care setting.
Kowitlawakul et al., (2015) mentioned that good handover not only is beneficial for the
patients but is also beneficial for the physicians and other health care professionals apart from
nurses. With the recent shift of the focus care to a more debatable culture within care systems,
accountability of the professionals has been prominent and drawn attention of all. Accountable
and clear communication protects against inconvenient attribution of charge for errors occurring
in due course of care. Under condition when updated and clear information is present as a
result of hand over, it is easier for physicians to take control of the care activities in a more

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confident manner. Handovers give the opportunity to get involved in early stage specialty care.
Well-led sessions for handover can set the foundation for clinical education whereby novice
professionals can engage in professional development. When best quality of care is provided it
is highly rewarding for professionals who experience an increased sense of job satisfaction.
Standard setting statement
Shift handovers must consider achieving a striking balance between efficiency and
comprehensiveness. The risk to healthcare service user and the care setting is to be reduced
through optimization of quality of care. The below mentioned overarching standards are
articulated to ensure that the transfer of service user information is smooth and effective. The
standards have been put in place considering the implications for clinical handover practices
among nurses.
Standard 1- The shift handover is to be undertaken in a professional manner. The involved
stakeholders are to demonstrate personal accountability by being positive and respectful about
the other professionals involved in the same process. Further, handovers are to be carried out
at a particular place within the setting and for adequate period.
Standard 2- The shift handover is to be undertaken as a well planned task. The handovers are
to be reflective of the written record and the information to be delivered is to be linked with the
care plan of the consumer. In addition, the needs of the oncoming officer are to be met through
cross checking the knowledge level of the professionals.
Details of the standard to be implemented
Professional with the responsibility of the handover
The shift leader at the ICU is to handover the details to the next team on duty prior to the
commencement of the shift. This would allow the members from the previous shift to be present
at that time for maintaining safety and delivering best quality care. All members of the team are
to be allowed for attending and a grade is to be present for attendance. The leader should make
sure that the team is informed about the details of the shift handover. Involvement of the shift
leader ensures that proper management decisions are taken, and the handover conveys the
seriousness of the clinical scenario. The Lead nurse is to make sure that each clinical handover
sheet has an electronic version that is stored in a secured and safe storage method. All

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members of the next shift are to be available for attending and participating in an active manner
in the handover process.
Time
The length of handovers would depend on the severity of the situation and the local
procedures. Depending on the local systems in place for working practice of staffs, there would
be two or three handovers each day. The staffs are to be present on time and have the
necessary preparations for attending the handover at the commencement of the shift. Further,
the staff is to access the comprehensive clinical notes during the process of handover, in
addition to ward dairy and communication book. The time of the handover would be known by
all staff.
Place
Handover is to take place in a designated place that can accommodate the entire team
taking part in the process. It is crucial that confidentiality is maintained while discussion is being
done about sensitive information. Arrangements are to be done so that the handover is carried
out in an environment not permitting disturbances and interruptions. It is advisable that a sign
reading ‘Do not disturb’ is put up for preventing interruptions. The shift leader of the previous
shift would be responsible for ensuring that there are arrangements made for observing and
supporting the service users while the handover is going on.
Method
All handovers would be carried out in a pre-determined format along with a robust
structure that paves the way for suitable exchange of information. The nurse lead is to oversee
the decision making process regarding handover template. The template is to be signed off
before use by the unit’s nurse lead. No deviation would be allowed from the decided template
that has been approved by the nurse lead. All staffs are to be given the updated version of the
copy. All issues pertaining to clinical rinks that are encountered during the handover are to have
the support of current care plans or risk management plans. The shift leader would have the
added responsibility of recording the designation and names of the attendant for every
handover. Electronic handovers are to be updated when a shift handover is over. The
information to be included in the handovers must be accurate and updated. Information related
to service users with specific problems is to be mentioned separately. Emphasis would be given

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to continuing management plans requiring urgent investigations. Short term and long term
changes are to be articulated clearly to foster resource allocation (Sonntag et al., 2016).
Delegation of duties after consultation with staff
After the handover is completed the shift leader would make sure that the duties and
tasks are prioritized in a clear manner to every staff member. The leader would also be
accountable for making sure that the staffs are competent enough for undertaking the delegated
duties. All nurses are to delegate the assigned duties retaining accountability. The physician is
to be informed on an immediate basis in case there is any deterioration in the health condition of
a patient. Additional handovers might be required for supporting the workforce and prioritizing
the workload. In case in any action is not completed the same would be documented so that
there is no loss of information.
Deadline for implementation
The deadline for implementation of the set standard would depend on the availability of
resources and consensus of all stakeholders. This might require minimum of two months but
might vary accordingly. It is to be remembered that the implementation needs to be smooth and
free of hindrances. Thus the setline would be set after ensuring that no major challenges would
be faced at later stages.
Communicating the standard to others
The newly set standard would be communicated to the stakeholders through a meeting
conducted at the workplace. The session has to be attended by all the professionals who play a
role in the handover process together with the physicians. The management body is to conduct
the meeting and the need of changing the present handover process is to be clearly
communicated. The benefits of the change proposed are to be defined and explained that can
set the foundation for change through preparedness of the professionals. The emotional
impacts of the proposed change are to be considered. The personal concerns are to be
considered while crafting the message to be forwarded. The requirements from the
professional’s end are to be clearly explained to them. The roles and task delegations are to be
clearly articulated so that there is no injustice done with any professional (Yoder-Wise, 2014).
Any emerging queries and doubts are to be resolved appropriately without any conflicts
of interests. An open two-way communication channel would be crucial for understanding the

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concerns of the professionals. If they are to be provided with answers to their questions, it would
be crucial to communicate in an honest manner. Speaking clearly has been noted as the key to
communication that fosters change in the workplace setting (Huber, 2017).
Evaluation of the effectiveness of the standard set
Monitoring process of the standard set would be crucial for understanding the
effectiveness of the same. The ICU’s nurse lead would be responsible for reviewing the present
arrangements of handover and planning the way in which the standards are to be adhered to.
When completed, the local arrangements are to be overseen. The lead would further coordinate
for monitoring the compliance with the set standards with the help of a regular audit. Auditing
has been denoted as a valuable tool for improving quality of care through adherence to set
standards (Esposito & Dal Canton, 2014). The audit would measure the clinical process of shift
handovers against the well defined standards outlined above. The focus of the audit would be to
bring into focus the discrepancies arising between the set standard and actual practice for
identification of areas of clinical practice needing improvement. The initiative would be
professional a expressed through clinical competence of the staffs, confidentiality of the result,
and objective connection between theory and practice. The achievement of carrying out a
successful audit might be reached through varied actions such as solving problems, increasing
the workforce’s culture of learning, and reducing t gap existing between real life scenarios and
theoretical standards.
Awareness of the set procedure and the utility would be an essential part of the
discussions with staff on ward induction. This would be a part of reflective practice and on-going
supervision adopted in the ICU environment with the clinical practitioners. The nurse leads are
to consult with the staff in context of further needs of support and training required by them with
the aid of processes for policy reviews. Training is to be provided to staff lacking the required
skills (De Silva et al., 2015).
Conclusion
Identification of high-risk situations for safety of patient is critical for ensuring betterment
of health services within a service setting. One of the most crucial areas for patient safety is shift
handovers which refers to the process of transfer of clinical data from one professional group to
another as a result of changes in working shifts. It has been identified in the ICU currently the
workplace that breakdown of communication is linked with poor shift handovers that increase

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the risks of sentinel events. Challenges faced while undertaking the process of shift handover
promote chances of human errors. For ensuring that patients safety is promoted, the nature of
the handover and the barriers faced have been identified appropriately for enhancing quality of
the handover process. An action plan has been put in place in the present paper that when
implemented would guide a better handover process within the ICU setting. With successful
engagement of all the stakeholders into the process, and suitable allocation of resources, it is
hopeful that significant improvements would be made in near future.

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