Maree Johnson1, Diana Jefferies, Daniel Nicholls. 1. Centre for Applied Nursing Research (a joint venture of the SSWAHS and UWS), Liverpool and School of Nursing & Midwifery, University of Western Sydney, Sydney, Australia. maree.johnson@sswahs.nsw.gov.au
Abstract
AIMS AND OBJECTIVES: This study presents a minimum data set designed for an electronic system to complement verbal nursing handover. Background. Poor communication of patient information at handover has been implicated in adverse events with changes to clinical handover being proposed as a solution. This study developed a minimum data set for an electronic patient summary tool. DESIGN; Using an observational design the scope of information being presented by nurses at handover was identified in relation to a generic Nursing Handover Minimum Data Set. METHOD: Patient handovers (n = 195) were observed and digitally recorded across diverse specialties. RESULTS: Content analysis confirmed the frequent use of the Nursing Handover Minimum Data Set items across all specialties. The use of the items was affected by the patient context and the clinical setting. Aged care patients often had several clinical alerts reported (pressure areas, falls risk). Rapid changes in patient condition in emergency emphasised the need for a focus on observations and presenting problems. Mental health and maternity required further refinement of the items. CONCLUSION: The generic Nursing Handover Minimum Data Set can direct nurses to give a comprehensive account of their patient's condition and care. The data set needs to be flexible and adaptable to the patient context and setting and complements structured content verbal handover. This minimum data set provides an excellent framework for system development by clinicians, managers and information technologists. Educators can use this tool to teach student nurses, new graduates and experienced staff, about the patient information to be presented at handover. RELEVANCE TO CLINICAL PRACTICE: The Nursing Handover Minimum Data Set for electronic nursing handover complements verbal handover and provides a tool to give clinicians access to comprehensive information about all patients within the ward area.
AIMS AND OBJECTIVES: This study presents a minimum data set designed for an electronic system to complement verbal nursing handover. Background. Poor communication of patient information at handover has been implicated in adverse events with changes to clinical handover being proposed as a solution. This study developed a minimum data set for an electronic patient summary tool. DESIGN; Using an observational design the scope of information being presented by nurses at handover was identified in relation to a generic Nursing Handover Minimum Data Set. METHOD:Patient handovers (n = 195) were observed and digitally recorded across diverse specialties. RESULTS: Content analysis confirmed the frequent use of the Nursing Handover Minimum Data Set items across all specialties. The use of the items was affected by the patient context and the clinical setting. Aged care patients often had several clinical alerts reported (pressure areas, falls risk). Rapid changes in patient condition in emergency emphasised the need for a focus on observations and presenting problems. Mental health and maternity required further refinement of the items. CONCLUSION: The generic Nursing Handover Minimum Data Set can direct nurses to give a comprehensive account of their patient's condition and care. The data set needs to be flexible and adaptable to the patient context and setting and complements structured content verbal handover. This minimum data set provides an excellent framework for system development by clinicians, managers and information technologists. Educators can use this tool to teach student nurses, new graduates and experienced staff, about the patient information to be presented at handover. RELEVANCE TO CLINICAL PRACTICE: The Nursing Handover Minimum Data Set for electronic nursing handover complements verbal handover and provides a tool to give clinicians access to comprehensive information about all patients within the ward area.
Authors: Hanna Suominen; Maree Johnson; Liyuan Zhou; Paula Sanchez; Raul Sirel; Jim Basilakis; Leif Hanlen; Dominique Estival; Linda Dawson; Barbara Kelly Journal: J Am Med Inform Assoc Date: 2014-10-21 Impact factor: 4.497