1. Standardizing the Documentation and Communication of the Nursing Plan of Care at the Handover Using HIT Gail Keenan PhD, RN PI, University of Illinois, College of Nursing Beth Yakel, PhD Co- PI, University of Michigan, School of Information Dana Tschannen, PhD, RN Field Research Director, University of Michigan, School of Nursing

2. Currently Funded by AHRQ (2004-2007) The presentation reports on the YR 1 findings of the study: HIT Support for Safe Nursing Care Multi-site study (8 unit – 4 organizations) and refinement of the Hands-on Automated Nursing Data System (HANDS) Method. 1 R01 HS015054-01- HHS PHS National Institutes of Health, Agency of Health Research and Quality (AHRQ)

3. HANDS Project Vision (1998-present) Nurses everywhere will use the HANDS standardized technology supported plan of care Method to document and communicate about nursing care at every handover

4. HANDS Core Project Teams  Support Team –Annie Browning, MSPH –Elizabeth Brough, MSN, PhDc –Sally Decker, PhD, RN –Sharie Falan, MS, RN –Yvonne Ford, MS, RN –Crystal Heath, MS, RN –Mary Killeen, PhD, RN –Deanna Marriott, PhD –Rachelle Ramos, BSN, RN –Santosh Udupi, MS –Linda Scott, PhD, RN –Julia Stocker, PhD, RN –Kathleen Sutcliffe, PhD –Marcy Treder, BSN –Dana Tschannen, PhD, RN  Administrative Team –Gail Keenan, PhD, RN – PI –Beth Yakel, PhD, Co-PI –Mary Mandeville, MBA, Director  National Policy Advisory Team –Carol Bickford, PhD, RN –Connie Delaney, PhD, RN –Barbara Frink, PhD, RN –Ada Sue Hinshaw, PhD, RN –Joan Shaver, PhD, RN –Judy Storfjell, PhD, RN

5. Goals of HANDS Project Standardize method for collecting and communicating plan of care information at the Handover that 1.Is useful to clinicians 2.Promotes continuity of care across nurses 3.Creates a national database of comparable, valid, and rich nursing data 4.Supports research to continuously improve nursing care and practice

6. Standardization Defined “….the process by which the form or function of an artifact or technique becomes specified (Feng, 2003)”

7. To STANDARDIZE – MUST…  Gather SAME Data ELEMENTS  Same TIME Intervals  Same TERMINOLOGIES  Same DATABASE Structure  Apply SAME Rules for Selecting, Recording, and Rating NANDA, NOC, and NIC Terms and Measures  Apply a common approach to standardize hand- off using HANDS care plans as foundation

8. HANDS Method Provides:  A common format and elements for entering and updating Plan of Care  A common database for storage and retrieval  Common terminologies to enter dx, interventions and outcomes –NANDA – Nursing Dx Terms = 167 –NOC – Nursing Outcome Terms = 330 –NIC – Nursing Intervention Terms = 514  A common structure (SHARE) for communicating about the Plan of Care at the handover

9. Research and HANDS Framework 1.Continuously scan literature for related evidence 2.Employ socio-technical research methods 3.Regularly update HANDS Framework to reflect latest evidence generated from 1 and 2

10. Use Socio-Technical Approach To achieve desired goals with technology (Berg, 1999)  Involve the users  Use multiple methods of evaluation – qualitative  Grow knowledge through continuous interation of the design, evaluation, and refine cycle

11. Multiples Methods Used  Surveys – repeated (R)– Baseline skills, trust, safety culture, knowledge N3, satisfaction with POC and N3  Observations pre-go live, hand-off (R)  Interviews, Meetings, Focus Groups (R)  Think-alouds (R)  Analysis of transaction logs

12. Core Safety Framework: HANDS Care Planning Method (Keenan & Yakel, 2005) Effective Nurse Communication Effective Nurse Handover

13. HANDS METHOD RN Requirements  Update (or Create 1 st ) Plan of Care at Handover –Re-Rate all NOC Outcomes (minimum) –Enter correct Tally for each NIC Intervention –Enter Care Period to closest 4 hour increment –As needed: prioritize NANDA diagnoses add new NANDA, NOC, and NIC terms resolve or inactivate NANDA Diagnoses & NOC Outcomes Adjust NIC Interventions  Use HANDS – (SHARE Format) at Handover  Complete HANDS Discharge Note

14. Comparison of Baseline Measures N units = 4, N RNs = 193 Comp Skills M (SD) Know NOC M (SD) Know NIC M (SD) Trust M (SD) Culture M (SD) Unit A 3.6 (1.2)1.8 (.8) 30.1 (6.3)22.2 (4.7) Unit B 3.2 (1.1)2.6 (1.2) 32.8 (8.3)23.6 (4.4) Unit C 3.9 (1.0)3.0 (.8)3.0 (.9)33.4 (5.9)25.3 (3.8) Unit D 3.6 (1.0)2.3 (1.1) 36.5 (7.9)25.8 (5.1) p.valu.012.000.001.002

15. Comparison of Baseline Measures N units = 4, N RNs = 193  No significant differences –nurses satisfaction with current care planning method (low satisfaction) –knowledge of NANDA

16. Term Meaning Reliabilites 3 months post go-live Unit# RNsTerms/RNAv Correct A10665% B11660% C--- D8679%

17. Observations of Report 3 Months Post  Ns –units = 3 ; –reports/unit = 2; –Total RNs all repots=14  Findings –2 units had access to HANDS Plan of Care in Handover – 1 had NONE –9 of 14 RN discussed at least on NNN term in handover –Format for unit report remained very close to original report format for each of 3 units

18. 6 month Post Go Live Interviews and Focus Group  N for Focus Group = off site ($50) –6 RNs (2 sites represented)  N for Interviews (on site)= $10 for 10” –39 RNs (all 4 sites) Tell whatever you want to say about what is and is not working about the HANDS Method

19. Positive Results 6 month Post Interviews and Focus Group agreed new Method was superior to old Some RNs reported exceptional satisfaction (- to +) Role models for heedfully interrelating in report (3 units) One unit used plans of care in rounds Ensure current plans of care were in chart Change was occurring and moving in the right direction Desiring revisions to original templates (language learning taking place)

20. Needs Improvement 6 month Post Interviews and Focus Group (cont)  RNs desired consistent handover format using Plan of Care to structure it  Difficult to access most current plan at handover  Some nurses not familiar with functionality needed to individualize plans  Education was variable and not completed by all RNs on unit

21. Integration of Finding into Next Steps – Year 2 Units  Training revamped and standardized  Units required to set-up means of tracking compliance with training and baseline competency  Handover structure has been standardized (SHARE at Computer) and included as a baseline competency  HANDS tool improved- –Provides access to Plan of Care an HX from Pt. List –Other enhancements that promote ease of use added –On-line tutorials – help available within the HANDS application

22. Method Meets 2 Major Mandates  American Nurses Association (Committee on Nursing Practice Information Infrastructure) GOAL to generate electronic interoperable nursing data across organizations  the Joint Commission on Accreditation of Healthcare Organization’s new Safety Goal (2006) requirement to “Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.”

23. SHARE Handover Structure S – Sketch = pt. name, age, gender, medical dx, code status, allergies, & other pertinent information H – HANDS = Review Plan of Care Hx and Current Plan – AT COMPUTER – add only those essential details A – Aim = discuss care focus of next shift R – Rationale = explain your thinking E – Exchange = invite questions, debate, dialogue

27. Questions???