In a complex environment like healthcare, effective communication amongst team members and with patients is essential for the care and safety of patients and for staff. Up to 70% of all healthcare errors have been attributed to issues of communication. Handoffs amongst staff, such as those done daily at shift changeover, are seen as particularly vulnerable times for the transfer of information and accountability, with the literature pointing to improved patient safety when both verbal and written communication are used at these junctures. As a nurse leader in a critical care unit (CCU), Jonathan noted that there were wide variances of handover practices amongst his colleagues, with inconsistency in the time it took to provide the information, the information passed on, and the details provided. He recounted times when he (or his peers) would call into the unit later after his shift had finished, remembering an important detail that he wanted to pass on but had forgot at the time. With no organized communication process in place, he found that handovers were loosely structured, with poorly defined handover practices in place. These shortcomings can result in increased job-related stress, deficits in patient care needs, and nurses focusing on work while at home. When dealing with acutely ill patients in areas such as CCUs, where low nurse-patient ratios allow for more detailed handovers, the timing of what is relayed, how, and when, is crucial to the care to be delivered.
Jonathan’s project aimed to develop and test a written handover tool for use by nurses at shift changeover in a CCU at Sunnybrook. The goal was to standardize the content of the tool, so that information relayed by nurses contained all of the relevant information to ensure the safe progression of care, and to help decrease the length of the verbal handover. Jonathan engaged staff in the development of a written tool, its format, as well as its content, using the SBAR (Situation-Background-Assessment-Recommendation) format, which is the structured communication tool for transfer of accountability at Sunnybrook. As Sunnybrook was also moving toward an electronic medical record (EMR), existing written tools and systems used by nurses were no longer in place, making this new written tool even more relevant at the time. The goal of the project was to encourage patient and family engagement early on in the shift, as information was being relayed, and to improve overall safety, communication, and patient and nursing satisfaction.
Jonathan was offered the opportunity to lead the implementation of the EMR within CCUs across Sunnybrook, which coincidentally was being implemented at the same time as his fellowship. In the end, he was able to use this to his advantage, using the time he had training nurses on the new EMR to also engage them in discussions about handovers in general, the processes they used for transfer of information and accountability, and to gather their feedback and insights into the content and format of the new SBAR tool he was developing. Concurrently, he was able to provide training to approximately 60% of the nurses within one CCU on the use of this new tool. Jonathan found that there was also an increase in the number of nursing using verbal + written communication for transfer of accountability rather than verbal only within his unit. He has received positive feedback from his peers regarding the tool, and sees it in use regularly on his unit.
Jonathan’s work has garnered interest from other CCUs at Sunnybrook, and he is currently in discussions about implementing the SBAR tool in those units as well. He has shared his work broadly within Sunnybrook, most recently presenting at ‘the gathering’, a best practice forum which brings together staff from all of the CCUs at Sunnybrook. As he continues to work on MetaVision to implement the EMR, he aims to integrate documentation for transfer of accountability within this system. He is also collaborating with the transfer of information working group and unit practice councils to apply this new tool to other transitional points (e.g. from CCU to the unit). He also plans to continue with the evaluation of the tool, in relation to how patients and families are engaged in the process, and related to adverse incidents in his unit.
While Jonathan was clearly on a leadership path (as team leader within the unit, being given the opportunity to lead the EMR implementation across CCUs at Sunnybrook), this fellowship appears to have opened many new doors for him, as he feels he was increased his networks and profile within Sunnybrook, garnering attention from senior leaders, and being asked to present at large internal forum with other well-known panelists. What is striking in Jonathan’s case is a new-found confidence, in his own abilities and what he is able to offer, and an assertiveness that he will not shy away from opportunities. Jonathan does not want to leave clinical practice, and he is currently enrolled in a nurse practitioner program. He envisions himself in a role that marries advanced clinical practice together with leadership in the area of quality improvement and project management. The skills gained through the fellowship program and being able to use the language of quality improvement, change management, and leadership will be well used in the future.
As with many things in life, this project did not unfold as planned, mostly due to Jonathan embarking on a new role with MetaVision as he was about to launch his own work as a fellow. The implementation of the EMR concurrently with his project created some complications in terms of the evaluation, as it may be hard to disentangle the implementation of the EMR with his own work related to communication and transfer of information and accountability. However, Jonathan was able to use his new role to his advantage, as he needed to strategize how to access nursing staff to help develop and pilot his tool. He was able to use the infrastructure provided by MetaVision and training of nurses, to also gain insights from and provide training for this group for his own project.
Jonathan exudes a new-found confidence, gained both from his new role as well as from the fellowship, and appears open to the opportunities before him, and in seeking new opportunities. The fellowship has helped him to see his own potential, in developing, implementing, and evaluating a project, creatively finding solutions to complete the work, and disseminating and spreading his work throughout Sunnybrook.
If you had one minute to speak about the fellowship, what would you say?
“This is an excellent initiative to develop people professionally, personally, and to help them feel more engaged with their profession and with their organization. I feel more engaged as a nurse, more part of Sunnybrook, I feel like I have more of a face at Sunnybrook.”