Nurses Develop Successful Handoff Tool for Patient Safety Attendants
December 1, 2023 7 minutes read
By Melinda Young
EXECUTIVE SUMMARY
Nurse residents and co-investigators created and successfully tested a simple communication tool, called Patient Safety Attendant Handoff Form, that helps improve safety and care quality for patients with personal safety attendants.
- The tool relies on the SBAR model: Situation/Background/Assessment/Recommendation.
- Research shows the handoff form improves communication between patient safety attendants and nurses.
- Instructions on the tool include checking in with the patient safety attendant every two hours.
When Rachel Holst, RN, was a nurse resident specializing in pediatrics, she was told to be a sitter for an adult patient in another area of the hospital. Holst entered the patient’s room, and the nurse she was relieving walked out, saying only, “Good luck.”
Next thing Holst knew, the patient was swinging arms, kicking legs, and Holst had no information about the patient’s condition and what to do to calm them.
“I didn’t know the patient’s name, and I was stuck with no number to call for help. I was left alone,” says Holst, a registered nurse at MercyOne North Iowa Medical Center.
This experience led Holst and a fellow new nurse to create a communication tool for nurses and sitters or patient safety attendants (PSAs) in the hospital. They launched a quality improvement project and published a paper on the tool.1
The solution was to use the evidence-based format of SBAR (Situation/Background/Assessment/Recommendation) in a patient safety attendant handoff form and to study how using the SBAR form improved communication. The PSA handoff form improved communication between PSAs and nurses and enhanced communication between PSAs.
“There was a lack of communication between sitters and nurses taking care of patients, so we developed the SBAR tool for handoffs to the oncoming shift,” says Paige Hawley, BSN, RN, co-author of the tool and a registered nurse with MercyOne North Iowa.
The tool can be helpful to anyone who visits the patient, including case managers. They can learn how to avoid patients’ triggers and keep themselves and the patient safe.
“Sitters or patient safety attendants are used when patients require one-on-one observation, 24/7,” Hawley explains. “This is for several reasons. One reason is when a patient is at risk of hurting themselves, suicide precautions, fall risk, and mental health issues. The use of sitters is to protect the patient from causing injury in some way.”
Some patients who require PSAs experience memory issues and may not know what is happening because the hospital seems new to them. “Being in a new environment can be agitating to the patient,” Hawley explains. “That can be a big trigger for patients who have memory issues.”
Another issue is that when a sitter would arrive for a shift, they often were left on their own for their entire shift. They could not leave the patient alone even to take a restroom break. The new handoff tool states that nurses must check in with PSAs every two hours.
One of the most common complaints listed in a preimplementation survey was that sitters did not feel they were given basic information about the patient — not even their name and code status and why they were hospitalized.
“They weren’t talking frequently enough with nurses,” Hawley adds. “The SBAR form has a reminder for the nurse to check in with the patient safety attendant.”
The goal was to focus on things that were most important for a patient, such as avoiding triggers. “We wanted them to use it to benefit the patient,” Hawley says. “In the post-implementation survey with PSAs using the SBAR forms, we found some were using it from PSA to PSA instead of from PSA to nurse.”
When Hawley and Holst started the project, the PSA position was not fully established. Often, sitters were pulled from other departments, such as the pediatric nursing unit.
“As we completed our project, the patient safety attendant position became established and recognized, and we used PSAs for the post-implementation survey,” Holst explains. (For more information, see the story in this issue on how the PSA handoff form works.)
Hawley saw how important it was for sitters to establish good communication with nurses. One of Hawley’s family members was in the hospital for a couple of weeks and required a sitter because of his dementia and fall risk.
“He was agitated,” Hawley says. “They were able to get a nurse in to tell us more information. While I didn’t get to see them in handoffs, it seemed like the patient safety attendant had a good idea of what was going on with my family member — even though they hadn’t been [the one] caring for him.”
The handoff form project is a good example of how a nurse residency program can promote evidence-based practice and help new nurses transition from graduated nurse to licensed nurse, says Tara Nichols, DNP, ARNP, CCNS, AGCNS, PMGT-BC, member of the advisory board for the nurse residency program at MercyOne North Iowa. In the program, nurse residents perform an evidence-based project, review hospital data, find gaps in care, and create a solution.
Hawley and Holst were well positioned to take on the project because of their experiences as new nurses and their problem-solving skills, says Jennifer Bredlow, MSN, RN, nurse residency program coordinator at MercyOne North Iowa.
“There wasn’t great research on this particular topic of sitters and SBAR, but looking across disciplines, identifying that gap, and creating a tool to use is amazing,” she says.
“These two young ladies looked at the relationship between nurses and sitters and found a communication gap,” adds Nichols, program director for the RN/BSN Program at Waldorf University in Forest City, IA.
Through a preimplementation survey, Holst, Hawley, and colleagues found sitters were not happy with the way things worked. They felt unsafe and did not have clear and concise information that was necessary.
The data showed the top reasons for sitter requests were all behavioral. “They were psychiatric diagnoses, pulling at lines, either being harmful to themselves or to others,” Nichols says.
PSAs needed to be always within eyesight of the patient. Sometimes, they were within an arm’s length; other times, they would sit at the patient’s bedside, Nichols says. The patients often are active, and the sitter needs to constantly redirect their hands so they do not dislodge the medical equipment.
“We try not to restrain people if we can avoid it,” Nichols notes. “Sometimes, they can’t be chemically restrained. We need them to stay awake.”
Although behavioral issues lead to the need for PSAs, these encounters are not taking place on a behavioral health unit. These are medical units. “Maybe the sitter took one psychology class and had a few hours of psychiatric experience,” Nichols explains. “Then, you may have a patient who is constantly pulling out the IV, or [urinating] on the floor, or throwing feces at you. This goes on all the time.”
Worse, the PSA who meets the patient for the first time may not have been given any information about the patient’s behavior and what triggers the outbursts.
“We have patients who also have behavioral issues, and you have to take care of the medical problems,” Nichols explains. “The whole dynamics of healthcare has caught up with the dynamics of the population, and we need a big healthcare system that can take care of the whole person — wherever they are.”
Another issue is the COVID-19 pandemic led to an escalation of emotional situations involving patients. “We definitely saw a shift in COVID and post-COVID in patients’ expectations,” Bredlow says. “Patients [may] get angry if we’re not meeting their needs or delivering care in a way they want.”
The nurse residency program explains escalation of emotions and what nurses can do in those situations. “You have a patient who acts out or is being violent or aggressive, so where do you go if you are working on the floor? Is there a code ‘white,’ or do you call security to come stand by if we know the patient will get aggressive?” Bredlow asks. “Sometimes, those aggressive behaviors are just going to happen, so what resources do we have to help [staff]?”
For instance, PSAs learn verbal de-escalation skills — how to talk to patients if they are becoming aggressive. “With SBAR, you communicate things that you can avoid, like certain triggers that will get the patient escalated,” Hawley says.
Behavioral problems are among the biggest challenges. “Mental illness comes on a continuum,” Nichols explains. “Sometimes, people feel sad, and sometimes they have chemical imbalances where they’re depressed, and sometimes they have schizophrenia — along with diabetes and hypertension, and [their conditions] are mismanaged.”
Providers cannot limit their care to the medical issues and ignore the behavioral health problems. They have to take care of the whole person, Nichols says. This entails understanding a little of why patients behave the way they do. Behavioral health professionals, experienced nurses, and social workers could help with this.
For instance, when a patient continually tries to pull out the indwelling urinary catheter and wants to use the bathroom, they may not be able to listen when the PSA or nurse tells them that they do not need to use the toilet because that is what the catheter is for, Nichols explains. They feel an urgency to urinate due to the catheter causing a stimulating sensation, and they fear they will wet themselves, even though the catheter prevents that.
“It keeps them from going to sleep, and they’re sleep-deprived and don’t make any sense,” Nichols says. “Then, they may start hallucinating and wake up and not go back to sleep until they go to the bathroom.” The solution may be to remove the catheter and let them use the bathroom, she adds.
The key is to meet patients where they are and to find ways to mitigate their behavioral health issues, communicating what each care practitioner has learned about each patient to the next person in the room. The handoff tool, which now is an official hospital form, accomplishes this.
“To me, the handoff form is very basic information we would expect to know, but it wasn’t getting communicated,” Holst says. “Now, it is being communicated, and it’s very successful and is a positive thing.”
REFERENCE
- Hawley P, Holst R, Bredlow J, Nichols T. Development of a communication tool for handoffs involving patients cared for by sitters: An evidence-based practice project. Creat Nurs 2023;29:109-124.
Nurse residents and co-investigators created and successfully tested a simple communication tool, called Patient Safety Attendant Handoff Form, that helps improve safety and care quality for patients with personal safety attendants.
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