Perceptions and Experiences of Hospital Nurses During Transition to an Electronic Handover Informatics System Lee, Chia-Lun MSN, RN; Lin, Wei-Ting PhD, RN; Lin, Shu Yuan PhD, RN
Author Affiliations: Kaohsiung Medical University Hospital (Ms Lee and Dr S.Y. Lin) and School of Nursing (Ms Lee and Drs W.T. Lin and S.Y. Lin), Kaohsiung Medical University, Kaohsiung, Taiwan. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
This research work was supported by research grants from Kaohsiung Medical University Hospital (KMUH104-M401), Taiwan. Corresponding author: Shu-Yuan Lin, PhD, RN, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Rd, Siamin District, Kaohsiung City 807, Taiwan (firstname.lastname@example.org).
Online date: August 5, 2019
An effective patient transfer, or handover, among healthcare professionals can help prevent communication-related medical errors, and a reliable electronic handover informatics system can standardize the handoff process. Adapting to a new handover system may cause stress for nurses.
This descriptive qualitative study aimed to explore the perceptions and transition experiences of hospital nurses in adopting and adapting to a new handover informatics system. Thirty-eight nurses at a medical center in Taiwan participated in the study from December 2016 to January 2017. The researcher conducted five focus group interviews and analyzed all responses using content analysis.
Results showed three major themes: “Perceptions of challenges and barriers related to the transition to a new handover informatics system,” “Perceptions of benefits and strategies to the transition to a new handover informatics system,” and “Suggestions for successful implementation
of a new handover informatics system.
Five subthemes emerged from the first theme, and six subthemes emerged from the second theme. The results of this study could enhance our understanding of nurses’ perceptions and experiences with transition to a new handover informatics system and could provide a reference for hospitals to develop individualized strategies to facilitate the implementation of a handover informatics system.
“Improving communication and safety for patient handover” and “Promoting the effectiveness of communication among healthcare professionals” were declared as national goals of patient safety by the Taiwan Joint Commission on Hospital Accreditation (TJCHA) in 2006. A good patient transfer, or handover, can help prevent communication errors to ensure patient safety. Studies have shown that handover via electronic technology can integrate and disseminate patient information more efficiently and accurately.
The development of electronic handover informatics systems (HISs) has been slow compared to the implementation of electronic medical records (EMRs) for diagnosis, prescription, and laboratory tests in Taiwan hospitals. Only 10% of 10 medical centers had totally completed computerized nursing handover information from 2009 to 2015. Advancing computer and informatics technology and legislation regarding EMR use announced in Taiwan have accelerated the use of EMR and HIS, although challenges and barriers still exist for nurses during implementation in hospital settings.
In this study, we explored the perceptions of hospital nurses when they experienced a transition to a new HIS, and we present the current body of knowledge related to handover and HIS issues. Back to Top Defining Common Handovers and Electronic Handover Informatics Systems Patient transfers are the most frequent occurrence among all healthcare activities. It is defined as a transfer of responsibility and accountability for patient care to another person or professional team.
Handovers frequently occur under circumstances such as nurses’ shift transfer on each ward, nurse-to-nurse interdepartmental transfers, and patient transfer between different professionals,12,13 and involve delivering patient care information, providing education, building social relationships with peers or colleagues, and demonstrating organizational safe culture. The common methods of handover include oral communication, documented information, taped records, and electronic technology.15 The handover delivered through an electronic informatics system that consists of minimum data sets of patient medical information and a nursing plan is called HIS.
To promote safer handovers, the TJCHA called for redesigned handover methods. Several projects have been conducted to evaluate outcomes of HIS use in Taiwan hospitals, and these projects have reported consistently that implementing the HIS could reduce handover time per patient by 1.1 to 4.5 minutes and increase the handover completion rate by 18.8% to 58.4% compared to the use of the oral handover method. Other projects found nurses’ satisfaction about HIS had increased by 19.3% to 50.0% after replacing oral and document-assisted handover.
Implementing the HIS could increase handover behaviors by 92.8% among interdisciplinary professionals in the oral surgery ward and increase the handover completion rate by 15.2% between interdisciplinary transfers for emergent operation cases. Consequently, the evidence supports the idea that HIS could promote effectiveness of handover procedures between nurses or different professionals. However, the barriers and challenges to effective handover procedures or using HIS have raised further concerns.
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Barriers and Challenges to the Implementation of Electronic Handover Informatics Systems
Nurse- and computer-related problems in the implementation of HIS have been reported.23,24 When nurses have inadequate computer skills and technical assistance, they prefer to use the traditional handover method rather than the HIS. Nurses also complain about time consumed by training, the burden of dealing with electronic information, and the extra workload and responsibility during a transition to the new handover method. Nurses report computer-related barriers including slow speeds of devices and Internet service, time consumed by logging on and off, difficulty finding information from other disciplines,
and having too much information on one Web page. Furthermore, inadequate devices, the incomplete informatics system, and unmet nurses’ needs in HIS design and function would decrease nurses’ acceptance of HIS. Other barriers are worthy of concern. First, the lack of standardized handover format or process manual may cause breakdowns in communication and decrease staff acceptance of HIS.9,26Second, dual-handover methods used concurrently might cause further staff burden and delay acceptance of the new method.
Third, nurses and physicians may rely on different sections of EMRs leading to communication problems such as delivering overlapping information, ignoring patients’ real conditions, and increasing communication errors. Therefore, understanding nurses’ perceptions and barriers regarding adoption of HIS should be the first step to promote acceptance of HIS. Back to Top Benefits and Strategies to the Implementation of Electronic Handover Informatics Systems A reliable HIS provides regular and timely patient information that enables nurses to capture a patient’s condition and improve compliance with the plan of patient care.
Taiwanese nurses have reported five benefits of using HIS: “HIS assists me to deliver a good handover,” “HIS enhances teamwork and capability for patient care,” “HIS makes the handover easy,” “HIS saves handover time,” and “HIS enables me to learn from other persons.” Other benefits of implementing HIS were to enhance the climate of team resource management, handover consistency, and use of HIS among interdisciplinary professionals. Positive outcomes of implementing HIS included an increased handover completion rate, an increase in nurses’ satisfaction, and a reduction of handover time.
Managers of nursing departments should apply strategies to strengthen the computer competencies of nurses, provide educational guidance, and meet staff needs regarding design functions of computer systems and Internet speed to encourage successful HIS delivery. Developing a standardized operating protocol, a framework for a minimum handover data set, and standardized handover tools could all enhance effective use of HIS. Training handouts and a comprehensive guidebook should be provided for learners and for trainers before introducing a new HIS.
When nurses feel satisfied about high-speed Internet service, easy access to Internet, and the setup of the HIS, they show positive attitudes about using it. Using informatics and technology in handover delivery to improve patient safety and care quality is a global focus. However, introducing a new HIS could be a stressful event for nurses in hospitals. Lack of a staff-centered implementation plan, ignorance of nurses’ perceptions, and inadequate support for informatics and technology can decrease or delay nurses’ acceptance of HIS. Consequently, this study aimed to explore the perceptions and transition experiences of hospital nurses in adopting and adapting to a new HIS.
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- Study Design
This descriptive qualitative study describes and analyzes the transition-related perceptions and experiences of nurses in a medical hospital in Taiwan. To increase trustworthiness of the study, criteria of credibility, dependability, transferability, and confirmability were adhered to in design, sampling, data collection, and analysis. To enrich the data and maximize sample representation, the convenience sampling method and one inclusion criterion were used to recruit nurses in the Table 1Opens a popup window Opens a popup Opens a popup window window study. Participants were nurses who needed to deliver a handover via HIS during shift changes.
The researcher announced recruitment information at the head nurses’ meetings, and head nurses introduced study information to staff nurses. Thirty-one full-time nurses and seven head nurses from 32 units voluntarily participated in the study. All participants were females with ages ranging from 23 to 50 years with a mean of 12 years of experience (Table 1). Participants worked at ICUs (23.7%), medical-surgical units (39.5%), and other units. Nearly 82% of participants were N2 and N3, which represented the distribution of nursing clinical ladder in the study setting.
Five focus groups were held from December 2016 to January 2017. The HIS used in this study was designed by the information technology (IT) department of the hospital in 2014, and it had undergone several minor modifications. Back to Top Instrument A semistructured interview guide was developed based on literature review and research purpose. The adoption of an HIS is perceived as a stressor that may outweigh a nurse’s ability to cope, and this change will facilitate a transition Table 2Opens a popup window Opens a popup Opens a popup window window process in which individual behavior and role function adapt to new circumstances.
The interview questions inquired about nurses’ perceptions of and experiences with their transition process and adaptation to HIS. Example questions are listed on Table 2. Back to Top Data Collection Procedures Each focus group consisted of seven or eight nurses. Every nurse was interviewed once and assigned to one focus group based on their work units. For example, nurses working in medical and surgical wards were assigned to the same group. Nurses from ICU or gynecological and pediatric wards participated in another two groups.
Each focus group interview was conducted for around 90 minutes without interruption. Focus group interviews were held in rooms with privacy and low noise. One head nurse trained in qualitative methods and experienced in focus group techniques moderated the five focus group interviews. Back to Top Data Analysis To increase credibility, all interviews were voice-recorded, and the recorded contents were transcribed verbatim to written documents. The first author facilitated focus group interviews, made observation notes during the process, and checked the accuracy of the transcribed content using tapes and interview notes.
We also invited the participants to provide feedback about the developed themes and interpretations of meanings to cross-validate the results.37 To enhance dependability, the first author and corresponding author read the transcribed content wordby-word, revisiting the raw data as many times as needed to gain insights and to note emerging ideas on the transcribed paper. The themes, subthemes, and extracted sentences were written in Mandarin; a person who was proficient in Mandarin and English translated these. The two authors cross-checked these translations to ensure their correctness and appropriateness.
To increase confirmability, they further analyzed the data deductively by hand and formulated descriptive coding for content analysis separately.38 Then, they applied the coding items to all transcribed content and independently classified the coding items into major themes and subthemes; finally, they cross-checked the themes and recoded the transcribed contents with mutual agreement.37 The themes and the most representative sentences were chosen, and English translations were finalized based on consensus of the two authors.
Frequency analysis verified descriptive themes by counting and summing up the numbers of sentences representative of each subtheme appearing in contents. To enhance transferability, analytic results were interpreted with caution, and the characteristics of the study sample and research setting were considered; limitations of generalizability in the study were also stated. This study was approved by the institutional review board of the study hospital. Researchers informed all participants, and they signed a consent form prior to the focus group interviews. To protect the participants’ privacy and confidentiality, only the researchers could use the recorded information. All transcribed content was assigned to aliases.
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- Frequency and Major Findings of Themes
Three themes emerged from content analysis (Table 3). In Table 3, frequency indicates the number of times mentioned by nurses across content relevant to themes and subthemes. The most frequently appearing theme was Table 3Opens a popup window Opens a popup window Opens a popup window “perceptions of challenges and barriers related to the transition to a new HIS.” There were five subthemes subordinate to it (Table 3), with the major findings presented as follows. Back to Top Perceptions of Challenges and Barriers Related to the Transition to a New Handover Informatics System
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Mismatch Between Handover Informatics System Design and Nurses’ Needs and Expectations
The content and design of the HIS were the most important concerns of the study participants. At the beginning of the HIS implementation, participants thought that the content design of the HIS did not match their needs. F1 N1 (ie, focus group 1, nurse 1) said, “We did not want to use the system because the content was not very comprehensive.” F1N2 said, “We found the system was unfriendly to use or navigate. Therefore, we were not willing to use it.” F5N1 said, “The design of the system should be compatible with the nurses’ needs and make it easier to use in clinical situations in order to shorten the work time.”
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Changes in Handover Delivery Methods At the beginning of the HIS implementation, participants expressed concern about stress related to changes in handover methods. They reported that they had difficulties in following the HIS format, which differed from writing up a report
in their own way. They also thought that the HIS was inconvenient and that a paper document was a more appropriate tool for handover delivery.
F1N5 said, “Originally, it was hard to implement the system due to differences in logic and habits in writing handover papers. Now I have to adjust my own logic of organization in order to match the HIS format.” F2N6 said, “It was really different to change the handover method from paper documents to the HIS in the beginning.” F4N2 said, “When we used paper documents to hand over information between different shifts, we could flip through the documents and find the information we needed instantly. It was more convenient.” F4N3 said, “It was very inconvenient to select the right patient and wait until the right page came up in the HIS.”
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Insufficient Technical Support Some participants noted that the computer equipment and Internet speed did not adequately support the performance of the HIS, especially for a large amount of patient data. There was often a lag between the function pages. F4N3 said, “Sometimes I feel like the system is really slow, especially when there is a large amount of information stored for patients with long hospital stays. I found it was hard to use in the beginning.” F4N5 said, “It takes so much time to switch between different function pages.
” F3N7 said, “Every time you change from one function page to another, not only does it take a long time, but it can also cause frequent crashes.” F2N3 said, “Computer crashing is a big issue, especially considering how often it happens.” F5N4 said, “Problems with the Internet connection really bothered me.” Furthermore, support from the IT department was insufficient. F5N2 said, “Sometimes it takes as long as a week to have the system problem fixed.”
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Nurses’ Emotional Insecurity and Emotional Stress
The participants recalled many disagreements and negative emotions at the beginning of the HIS implementation. Some participants felt that it was unsafe to deliver handover information through the HIS. F1N7 said, “I felt insecure about the absence of the actual paper document.” Some nurses also were concerned about information security and loss of patient information. F4N3 said, “In the beginning, a lot of information was lost during the handover between shifts.” F1N8 said, “When the HIS was first implemented, the entire unit was opposed to it. We talked openly about our disagreement with its implementation because we really felt that abandoning paper documents was neglecting patient safety.”
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Insufficient Competency and Training
The participants reported that they were not familiar with the functions of the HIS and were unable to operate it correctly at the beginning when the HIS was first being implemented. F1N3 said, “It is true that people did not make maximal use of the HIS. Sometimes we didn’t make full use of this system because we were not aware of certain functions.” Inconsistencies of handover demands between staff and cross units were disturbing to nurses. F1N8 said, “Other units would ask us to use paper documents for handover delivery. Some units still used the old methods for handover.
” The participants mentioned that the nursing department offered courses and some trainers for the HIS, but trainers’ roles and functions did not play well. F5N3 said, “Every unit has its own HIS trainer. However, they do not seem to function properly. I don’t think they have achieved their purpose.” Back to Top Perceptions of Benefits and Strategies to the Transition to a New Handover Informatics System The second most frequently addressed theme was “perceptions of benefits and strategies to the transition to a new HIS.” Six subthemes were subordinate to it (Table 3).
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Convenience of Using the Handover Informatics System
Participants realized the benefits of the HIS as they became more familiar with it. Some participants agreed that the HIS had become convenient a …