Acute-To-Home Care Nursing Handoffs: Distributed Cognition Across Patterns of Knowledge
Timely, explicit, and effective communication of patient information during care transitions is fundamental to safe care. Studies show that handoffs or transfers of patient care from one provider to another are susceptible to communication failures (Riesenberg et al., 2009a). Most studies on communication failures focus on communication between providers within the same setting of care. Few studies, if any, focus on communication between care settings in different locations. However, research has identified gaps in care during critical transitions and identified poor communication and incomplete transfer of information as the root cause (Naylor et al., 2004). This qualitative dissertation consists of seven research questions aimed at understanding dimensions of nursing roles, patterns of communication, data exchanged and communication channels related to acute-to-home care handoffs. This study uses an integrated theoretical framework encompassing cognition theory, patterns of knowledge theory, and clinical communication space theory, which in parallel, represent key aspects of acute-to-home care handoffs. To describe these concepts and variables, the Event Analysis of Systematic Teamwork methods were used to describe acute-to-home care patient handoff distributed cognition and patterns of communication related to: role dimensions, tasks, and activities within the handoff process; data, information and knowledge shared; and communication channels used. In addition, the study described how the International Classification of Nursing Practice (ICNP) and the Quality Data Model (QDM) represent communication of nursing diagnoses and goals as patients transition from acute-to-home care settings. The study revealed a very complex and fragmented process devoid of acute-care nursing representation in decision-making regarding post discharge care and in sharing of data in the acute-to-home care handoff. A comparison of medical versus nursing diagnoses shared in acute-to-home care handoffs revealed that less than 7% of the inpatient nursing diagnoses were shared, while over 80% of the inpatient medical diagnoses were shared in the acute-to-home care handoff. Furthermore, inpatient nursing plan of care on the day of discharge is not shared in acute-to-home care handoffs. However, when the home care nurse completes the initial home care visit, the problems and goals on the home care plan of care reflect similar domains of care as the inpatient day of discharge plan of care. But the plan of care in the acute-to-home care handoff has no nursing care content. This black box between inpatient care and home care is revealed when the patient tells their story and the home care nurse performs an assessment that leads to a plan of care. This is exacerbated by single threaded one-way communication channels during the acute-to-home care handoffs. This study demonstrated how patterns of knowledge (handoff content) when sent through communication channels (electronic, face to face, handwritten notes and phone) that enable shared cognition and collaboration, are more effective. The study revealed that nursing documentation in the inpatient record is not used by anyone on the clinical team for the acute-to-home care handoff. A review of the artifacts revealed a strong medical model of information exchange, potentially demonstrating a continuation of medical care following physician orders. Furthermore, inpatient nursing plan of care on the day of discharge is not shared in acute-to-home care handoffs. However, when the home care nurse completes the initial home care visit, the problems and goals on the home care plan of care reflect similar domains of care as the inpatient day of discharge plan of care. However, the plan of care in the acute-to-home care handoff has no nursing care content. These findings are consistent with the literature. The concept of a dynamic plan of care that is not relinquished upon discharge warrants investigation. The results of this study will inform future efforts related to process improvement and data standardization for purposes of facilitating coordination of care across the care continuum.
acute to home care handoffs, care coordiantion, handoffs, nursing, transitions of care
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