Exploring Patient-Centered Handoffs in Surgical Oncology
The results of this study indicate that the majority of oncology inpatients would like to participate regularly in nurses' handoffs – as long as they are awake and feel well enough to do so. This positive attitude was echoed in findings from studies with non-oncology patients who participated in nursing handoffs in Australia and Europe. Two subsets in this study expressed firm opinions – one wanting to participate and the other seeing participation as not necessary or not part of their role as a patient. Overall, oncology inpatients saw more active participation as beneficial to improve communication and to plan for discharge. This would also alleviate patients from feeling like they are "in the dark" and help them understand inpatient care processes which were a mystery to some participants. It would also ease the abrupt change from being a passive recipient of care as an inpatient to suddenly assuming self-responsibility for all care upon discharge.
Expanding handoff communication to include patients is consistent with general directions in the e-patient movement and efforts in the patient-centered outcomes research institute. This direction is also consistent with a major theory in nursing that advocates patients' participation in their own care and patient/nurse mutual goal setting. Nurses have a long tradition of working with patients to achieve self-efficacy, although this work has not yet been extended to handoffs. Last, patient satisfaction ratings may improve as was seen in the two earlier, less formal studies and may be extended to other patient satisfaction ratings, eg Joint Commission in the US.
A small subset of patients did not want to participate in handoffs. Some were even surprised about us asking about patient participation. This could be attributed to the current health care culture that views clinicians as all-knowing and patients as passive recipients. Obviously, this belief creates a challenge for obtaining consistent participation by patients. Nurses will need to learn techniques to encourage handoff participation for this subset, customizable based upon how fervent they are about not participating. A simple intervention could be establishing a goal of participation at least once a day or scheduling participation with a family member.
Although several wanted to be proactive, participants also discussed a more traditional role of feeling dependent, complacent and passive in order to not "rock the boat" while an inpatient. They did not want to overstep their perceived boundaries as a patient and felt that they had to cooperate to receive the best care. They felt vulnerable and "in the dark" about care processes. "I'm just living out in this world here. Really, all I do is have about four doctors come in and throw a bunch of questions at you and then they're out the door."
A major change is needed to move away from the more traditional patient roles characterized by dependency and vulnerability. Both nurses and patients need education and tactics for this change to occur. For example, expected behaviors for these new, proactive patient roles would need to be made explicit upon admission to the unit. Nurses need to know to invite patients into the handoff process by asking questions and making patients feel like they are a valued part of the process. The latter was also a finding in a study about patient participation in overall nursing care in Australia. Institutional leaders would need to support this change, assure its even implementation, have policies in place to encourage patient participation in handoffs as well as other activities and support these new processes, especially during the initial transitions. Leaders need to be aware that patient-centered handoffs may be more time-consuming initially as nurses translate medical terminology into lay terms and explain implications of care decisions. Thus, effecting this change is a joint responsibility among patients, providers, and institutions.
The vast majority of participants want to know "everything" about their inpatient care, including prognosis. A subset was firm about being a part of handoffs, saying "…I'm the patient, after all." Patients would like to see discharge planning and medications in particular as part of the information exchanged during handoffs. The importance of including medication information in handoffs is consistent with findings from Australia. Patient knowledge about discharge plans, medications, and self-care needs should support a smooth transition from the hospital to home.
At first glance, two themes seem contradictory (patients wanting to know all information and yet conveying perceptions about being powerless). Rather than being contradictory, these may show patient readiness for change (wanting information) although they are stymied by the current hospital culture.
Most participants found information on the room whiteboard helpful, especially the names of providers, but usage varied. None of the participants used electronic tools, and only four used paper and pen to track information. On the other hand, no participants used electronic devices, which the authors expected would be the case for at least for some of the participants. The reasons for this might be that inpatient care was not deemed complex enough to require a tool other than paper or this sample may not be technologically savvy.
Informatics implications from this study are several. Patients want to know "everything" but only about half see the need for any tool to manage inpatient care. This group did not mention the need for an electronic device or tool. There are several possible reasons for this: being a "good patient," lack of knowledge about potential tools and the absence of devices in patients' rooms. A tailored, concise tool to support inpatients during handoffs may be useful. Optimizing the use of the room whiteboard would be fruitful, making its use more consistent, and making whiteboards electronic. Electronic whiteboards could be integrated with the patient's EHR. A more dynamic tool could allow patients and families to post questions for the health care team to address. Family members also could be informed of the patients' status through electronic means. This kind of tool could bridge the current divide in care responsibilities from inpatient to discharge. A more complex patient tool to manage the continuum of oncology care across environments is needed spanning home, clinic, infusion center, inpatient, and/or hospice.
Discussion
The results of this study indicate that the majority of oncology inpatients would like to participate regularly in nurses' handoffs – as long as they are awake and feel well enough to do so. This positive attitude was echoed in findings from studies with non-oncology patients who participated in nursing handoffs in Australia and Europe. Two subsets in this study expressed firm opinions – one wanting to participate and the other seeing participation as not necessary or not part of their role as a patient. Overall, oncology inpatients saw more active participation as beneficial to improve communication and to plan for discharge. This would also alleviate patients from feeling like they are "in the dark" and help them understand inpatient care processes which were a mystery to some participants. It would also ease the abrupt change from being a passive recipient of care as an inpatient to suddenly assuming self-responsibility for all care upon discharge.
Expanding handoff communication to include patients is consistent with general directions in the e-patient movement and efforts in the patient-centered outcomes research institute. This direction is also consistent with a major theory in nursing that advocates patients' participation in their own care and patient/nurse mutual goal setting. Nurses have a long tradition of working with patients to achieve self-efficacy, although this work has not yet been extended to handoffs. Last, patient satisfaction ratings may improve as was seen in the two earlier, less formal studies and may be extended to other patient satisfaction ratings, eg Joint Commission in the US.
A small subset of patients did not want to participate in handoffs. Some were even surprised about us asking about patient participation. This could be attributed to the current health care culture that views clinicians as all-knowing and patients as passive recipients. Obviously, this belief creates a challenge for obtaining consistent participation by patients. Nurses will need to learn techniques to encourage handoff participation for this subset, customizable based upon how fervent they are about not participating. A simple intervention could be establishing a goal of participation at least once a day or scheduling participation with a family member.
Although several wanted to be proactive, participants also discussed a more traditional role of feeling dependent, complacent and passive in order to not "rock the boat" while an inpatient. They did not want to overstep their perceived boundaries as a patient and felt that they had to cooperate to receive the best care. They felt vulnerable and "in the dark" about care processes. "I'm just living out in this world here. Really, all I do is have about four doctors come in and throw a bunch of questions at you and then they're out the door."
A major change is needed to move away from the more traditional patient roles characterized by dependency and vulnerability. Both nurses and patients need education and tactics for this change to occur. For example, expected behaviors for these new, proactive patient roles would need to be made explicit upon admission to the unit. Nurses need to know to invite patients into the handoff process by asking questions and making patients feel like they are a valued part of the process. The latter was also a finding in a study about patient participation in overall nursing care in Australia. Institutional leaders would need to support this change, assure its even implementation, have policies in place to encourage patient participation in handoffs as well as other activities and support these new processes, especially during the initial transitions. Leaders need to be aware that patient-centered handoffs may be more time-consuming initially as nurses translate medical terminology into lay terms and explain implications of care decisions. Thus, effecting this change is a joint responsibility among patients, providers, and institutions.
The vast majority of participants want to know "everything" about their inpatient care, including prognosis. A subset was firm about being a part of handoffs, saying "…I'm the patient, after all." Patients would like to see discharge planning and medications in particular as part of the information exchanged during handoffs. The importance of including medication information in handoffs is consistent with findings from Australia. Patient knowledge about discharge plans, medications, and self-care needs should support a smooth transition from the hospital to home.
At first glance, two themes seem contradictory (patients wanting to know all information and yet conveying perceptions about being powerless). Rather than being contradictory, these may show patient readiness for change (wanting information) although they are stymied by the current hospital culture.
Most participants found information on the room whiteboard helpful, especially the names of providers, but usage varied. None of the participants used electronic tools, and only four used paper and pen to track information. On the other hand, no participants used electronic devices, which the authors expected would be the case for at least for some of the participants. The reasons for this might be that inpatient care was not deemed complex enough to require a tool other than paper or this sample may not be technologically savvy.
Informatics implications from this study are several. Patients want to know "everything" but only about half see the need for any tool to manage inpatient care. This group did not mention the need for an electronic device or tool. There are several possible reasons for this: being a "good patient," lack of knowledge about potential tools and the absence of devices in patients' rooms. A tailored, concise tool to support inpatients during handoffs may be useful. Optimizing the use of the room whiteboard would be fruitful, making its use more consistent, and making whiteboards electronic. Electronic whiteboards could be integrated with the patient's EHR. A more dynamic tool could allow patients and families to post questions for the health care team to address. Family members also could be informed of the patients' status through electronic means. This kind of tool could bridge the current divide in care responsibilities from inpatient to discharge. A more complex patient tool to manage the continuum of oncology care across environments is needed spanning home, clinic, infusion center, inpatient, and/or hospice.
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