Original Article

Implementation of an Evidence-Based
Practice Nursing Handover Tool in Intensive
Care Using the Knowledge-to-Action
Framework
Amy J. Spooner, RN, BN, Grad Dip ICU • Leanne M. Aitken, B HSc (Nurs) Hons, Grad
Dip Sc Med (Clin Epi), PhD, FACN, FAAN, Grad Cert Mgt, IC Cert •
Wendy Chaboyer, RN, BSc (Nurs) Hons, MN, PhD

ABSTRACT
Keywords Background: Miscommunication during handover has been linked to adverse patient events
handover, and is an international patient safety priority. Despite the development of handover resources,
minimum data set, standardized handover tools for nursing team leaders (TLs) in intensive care are limited.
nursing, Aims: The study aim was to implement and evaluate an evidence-based electronic minimum data
knowledge-to- set for nursing TL shift-to-shift handover in the intensive care unit using the knowledge-to-action
action, (KTA) framework.
evidence-based
Methods: This study was conducted in a 21-bed medical-surgical intensive care unit in Queens-
practice
land, Australia. Senior registered nurses involved in TL handover were recruited. Three phases
of the KTA framework (select, tailor, and implement interventions; monitor knowledge use; and
evaluate outcomes) guided the implementation and evaluation process. A postimplementation
practice audit and survey were carried out to determine nursing TL use and perceptions of
the electronic minimum data set 3 months after implementation. Results are presented using
descriptive statistics (median, IQR, frequency, and percentage).
Results: Overall (86%, n = 49), TLs’ use of the electronic minimum data set for handover and
communication regarding patient plan increased. Key content items, however, were absent from
handovers and additional documentation was required alongside the minimum data set to con-
duct handover. Of the TLs surveyed (n = 35), those receiving handover perceived the electronic
minimum data set more positively than TLs giving handover (n = 35). Benefits to using the
electronic minimum data set included the patient content (48%), suitability for short-stay patients
(16%), decreased time updating (12%), and printing the tool (12%). Almost half of the participants,
however, found the minimum data set contained irrelevant information, reported difficulties nav-
igating and locating relevant information, and pertinent information was missing. Suggestions
for improvement focused on modifications to the electronic handover interface.
Linking Evidence to Action: Prior to developing and implementing electronic handover tools,
adequate infrastructure is required to support knowledge translation and ensure clinician and
organizational needs are met.

INTRODUCTION ICU nursing TLs oversee nurses at the bedside and are
Until recently, there have been limited resources available to responsible for coordinating and managing care for multiple
support nursing handover in the intensive care unit (ICU). critically ill patients with complex healthcare needs. TLs rely on
Clinical handover is a top five preventable safety issues informative handovers to maintain care continuity following
worldwide leading to adverse patient events and unnecessary shift changes and play a pivotal role in ensuring ICU patients
healthcare expenditure (Starmer et al., 2013). Although re- receive optimal care. Our previous work identified the content
search outlining various aspects of ICU handover is growing, required in nursing TL handovers and informed the develop-
there are limited standardized tools applicable to nursing team ment of an electronic minimum data set (eMDS) for shift-to-
leader (TL) handover. shift handover (Spooner, Aitken, Corley, & Chaboyer, 2017).

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Implementing an Evidence-Based Practice Nursing Handover Tool

Recently, electronic handover tools have received attention as a METHODS

possible strategy to improve communication and reduce hand- This study was conducted between January and June 2016 in
over related incidents (Balka, Tolar, Coates, & Whitehouse, a 21-bed adult medical-surgical ICU, specializing in cardio-
2013; Staggers, Clark, Blaz, & Kapsandoy, 2011). Many thoracic surgery at a tertiary referral hospital, in Queensland,
healthcare areas have developed electronic templates that Australia. Ethical approval was obtained by the institutional
autopopulate content from multiple sources within the (HREC/10/QPCH/5) and university (NRS/09/13) Human Re-
clinical information system (CIS) or are updated manually search Ethics Committee.
by clinicians (typing in free text boxes); eliminating handover
preparation time (Silvester & Carr, 2009). The introduction Setting
of electronic handover tools has increased efficiency, reduced The ICU consists of three areas (ICU (a): cardiac surgical,
time spent handwriting notes, decreased duration of handover, (b) and (c): general); each area containing up to nine patients
increased adherence to handover protocols, and clinicians coordinated by one TL. There were 180 registered nurses em-
have reported finishing work on time (Balka et al., 2013; Li, ployed in the ICU including 63 senior registered nurses work-
Ali, Tang, Ghali, & Stelfox, 2013; Ryan, O’Riordan, Tierney, ing in TL roles. Handovers occurred at the nurses’ station
Conlon, & Ridgway, 2011). within each area.
The integration of evidenced-based strategies into practice,
such as an eMDS for nursing TL handover, can be challenging. Participants
Knowledge translation frameworks provide a structured and All nursing TLs were invited to participate. All TLs worked
systematic approach to translate knowledge into practice, across the three ICU areas. Potential participants were told
which promotes and sustains practice change (Davison, about the study at staff meetings. Written consent was ob-
Ndumbe-Eyoh, & Clement, 2015; Field, Booth, Ilott, & tained prior to study commencement and confirmed during
Gerrish, 2014). The knowledge-to-action (KTA) framework is data collection.
one of the most frequently cited conceptual frameworks used
in healthcare settings to support researchers and clinicians Electronic Minimum Data Set
implement evidence-based practice (Field et al., 2014). The An eMDS was built within the MetaVision (iMDsoft R
, 2017)
framework incorporates existing change theories from health, CIS over a 6-month period (June–December 2015) in collab-
social sciences, education, and management fields to provide oration with the on-site CIS coordinator and Hospital Health
user-friendly action phases to consider during the knowledge Service information technology department. The eMDS was
translation process, which was utilized in this research. Guided structured using the ISBAR (Identify-Situation-Background-
by the KTA, researchers and clinicians engage with end users Assessment-Recommendation) mnemonic and additional con-
to identify gaps in practice, align new knowledge to the local tent items considered pertinent to ICU nursing TL handover,
context, which informs implementation strategies to embed identified in previous research (Spooner et al., 2017). Within
evidence-based practice (Field et al., 2014; Lockwood, Stephen- the “Assessment” category of the ISBAR mnemonic, TLs ac-
son, Lizarondo, van Den Hoek, & Harrison, 2016). End users knowledged and discussed significant detailed information
act as informants throughout the implementation and evalua- within each body system (i.e., Respiratory system) to provide
tion process. The KTA framework comprises two components: a thorough overview of the patient. For example, when TLs
knowledge creation and action. Knowledge creation is the pro- acknowledged the “social system,” information regarding fam-
duction of knowledge and consists of three phases—knowledge ily or care giver issues and needs were discussed. In addition
inquiry, knowledge synthesis, and creation of knowledge for to ISBAR, TLs mentioned alerts (allergies, infectious status,
best practice (Graham, Tetroe, & Theories Research Group, patient incidents) and patient management strategies (end-of-
2007; Lockwood et al., 2016). The Action component guides life plan, investigations). As TLs are also shift coordinators,
the implementation process for change and sustainability they handed over managerial information regarding admis-
consisting of seven phases—identify the problem; adapt sions, discharges, skill mix, and theatre cases coming to ICU.
knowledge to the local context; assess barriers to knowl- An eMDS for each patient was generated and information was
edge use; select, tailor, and implement interventions; monitor mostly autopopulated from multiple sources within the CIS. A
knowledge use; evaluate outcomes; and sustain knowledge use. free text box was provided with each eMDS to add additional
Utilizing the KTA framework, the study aim was to imple- information not included in the tool. Wi-Fi was unavailable dur-
ment and evaluate an eMDS for ICU nursing TL shift-to-shift ing the study period; therefore, smart devices were not used.
handover. This research sought to answer three questions: Instead, an eMDS for each patient was printed from the CIS to
facilitate bedside handover.
(1) What strategies should be used to implement an
eMDS for handover?
Data Collection
(2) To what extent did TLs use an eMDS for handover? The Action cycle from the KTA framework guided knowledge
(3) What were TL’s perceptions of an eMDS for han- translation. Phases 4, 5, and 6 informed the implementation
dover? and evaluation process for this research.

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Phase 4: Select, tailor, implement interventions. Our were observed once giving handover and any number of times
previous work identified the barriers and facilitators to eMDS receiving handover. The audit tool contained three sections
use (Spooner, Aitken, & Chaboyer, 2017). Barriers consisted (a) demographics, (b) general handover information, and (c) ad-
of knowledge deficits regarding the ICU handover work unit herence to the ISBAR mnemonic and other key content items
guideline and an eMDS that was not user friendly, time (Spooner et al., 2017). The audit criteria were either met or not
consuming, and contained too much information. Facilitators met.
included TL familiarity with most work unit guidelines and The audit tool was scrutinized by an expert panel of six
a user-friendly eMDS that saves time and contained relevant experienced nurses including two PhD supervisors, a Quality
information. These findings informed four strategies selected and Safety Clinical Nurse Consultant, Clinical Nurse, Clini-
to implement the eMDS into ICU. The investigators selected cal Nurse Teacher, and Clinical Nurse Consultant in ICU for
interventions from recent systematic reviews and multiple face validity. Next interrater reliability was established (ࣙ80%
strategies were utilized due to the cumulative and significant agreement) between three auditors and then data collection
effect shown to promote practice change (Effective Practice commenced (Polit & Beck, 2012).
and Organisation of Care, 2016; Grimshaw, Eccles, Lavis, Hill,
& Squires, 2012). First, 30-min interactive education sessions Phase 6: Evaluation outcomes. A survey was distributed to all
were used to target knowledge deficits. A video focused on TLs (n = 63) 3 months post-eMDS implementation to assess
safety issues, the national handover standard, the ICU han- their perceptions of using the eMDS for handover. Surveys
dover work unit guideline, handover resources, and real-life were placed on the ICU central desk along with an opaque
handover scenarios to critique. TLs were also given hands on envelope to collect completed surveys each day for 3 weeks. E-
training using the eMDS (Grimshaw et al., 2012). Second, a mail reminders were sent each week. The “Clinical Handover
small group of TLs and nursing management were recruited as Staff Survey” (O’Connell, Macdonald, & Kelly, 2008), widely
“champions” to be the driving force of change through develop- used in handover research, was adapted to the ICU setting
ing positive relationships with nurses, challenging the barriers, and consisted of four sections: (a) demographics, (b) TL per-
educating and supporting TLs to use the eMDS (Effective Prac- ceptions of handover (25 items), (c) perceived strengths and
tice and Organisation of Care, 2016). Third, regular reminders limitations of handover, and (d) suggestions for improvement.
regarding the eMDS were placed on posters at handover loca- TLs were asked to rate their perceptions related to a series of
tions and sent via emails to increase nurses’ recall of handover statements on a 7-point Likert scale ranging from “strongly dis-
knowledge and further embed the use of the tool (Effective Prac- agree” to “strongly agree” and each item was given a score from
tice and Organisation of Care, 2016). Instructions and short 1 to 7. Nurses answered open ended questions relating to the
reference guides were placed on computer desktops fastened strengths and limitations of the eMDS and made suggestions
to computer monitors to act as prompts. Fourth, ad hoc audit for improvement.
and feedback was used during the first 4 weeks of eMDS imple- Although the survey tool has been previously assessed for
mentation. A clinical research nurse (AS) attended various han- face validity, the tool underwent further scrutiny by four expert
dovers, 7 days a week during night-to-day or day-to-night shift nurses (two ICU nurses, a PhD student, and PhD supervisor).
handover. Consistent with the feedback intervention theory, a During Phase 5, face validity (readability, understandability,
behavioral change theory, TLs were given feedback regarding relevance, ease of response) and content validity (clarity,
their use of the eMDS and goals were set to redirect their focus consistency and content) were assessed using a 2-point
of attention during handover to promote behavior change scale with “clear” or “unclear” and “Yes” or “No” responses
and efficient use of the eMDS (Kluger & DeNisi, 1996). The (Imle & Atwood, 1988). Although the initial content validity
research nurse also assisted staff with troubleshooting issues index was more than 0.8 (clarity: 0.89, consistency: 0.89,
and gained feedback about the eMDS, which informed modifi- and content: 1.0 Scale-Content Validity Index and Universal
cations to the electronic interface to ensure the eMDS was user Agreement), questions were revised until perfect agreement
friendly and efficient to navigate. This strategy relied on par- was achieved (Polit & Beck, 2012). The survey tool was pilot
ticipant involvement to facilitate optimal use of the handover tested at two different time points by eight TLs in the ICU to
tool. establish test-retest reliability (83% of nursing TLs had perfect
agreement or 1-point difference in responses at two time
Phase 5: Monitor knowledge use. Three months post-eMDS points).
implementation, 49 handovers were audited over 25 days
(Monday–Friday) to determine the extent of TL use of the
eMDS during handover. A random number generator sam- Data Analysis
pled one TL per handover from the three ICU areas dur- Descriptive statistics were used to summarize data from the
ing the night-to-day (0700–0730 hr) and day-to-night shift post eMDS-implementation audit and survey. Data are pre-
(1900–1930 hr) handover. Handovers were observed if the on- sented as median, interquartile range, frequency, and percent-
coming and outgoing nurse provided consent to participate age. Responses to open-ended questions and the frequency of
and had not been previously observed handing over. Nurses recurring responses are summarized.

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RESULTS Table 1. Postimplementation Observation Participant

Phase 5: Monitor Knowledge Use Characteristics (N = 49)
Three months following eMDS implementation, 49 of 63
(78%) TLs were observed performing handover (49 nurses giv-
ing handover, 49 nurses receiving handover) resulting in 322 Demographics Frequency (%) Median IQR
patient handovers and a median of seven (IQR 3) patients dis- Gender
cussed at each handover. Table 1 provides a summary of these
Female 35 (71)
observations. Participants were mostly female, and experienced
ICU nurses. Slightly more than half of the handovers were ob- Male 14 (29)
served from the night-to-day shift. Most handovers were per- Nursing grade
formed using the eMDS to conduct handover, alongside other
paper and electronic print-outs. Nurse grade 6 23 (47)
Audit findings are detailed in Table 2. Almost two thirds Nurse grade 5 26 (53)
of TLs referred to unit flow and management (admissions,
Years nursing 16 11
discharges, staffing, skill mix, and equipment issues) of the
ICU. Most TLs structured their handovers using the ISBAR Years working in ICU 13 10
mnemonic. Within the Identify category over three quarters of Years working as TL 6 8
nurses referred to three patient identifiers to discuss patients,
Shift
however, only one patient’s medical identification number was
mentioned in 322 patient handovers. More than half of the Night-day 29 (59)
handovers contained information regarding patient diagnosis, Day-night 20 (41)
reason for admission to ICU, and surgical procedure, however,
only 6% of handovers contained information about resuscita- Handover time (min) 29 9
tion plans in the Situation category. Patient plan within the Overtime (min) 26 (53) 2 10
Recommendations category was the only item routinely dis-
Handover started late 31 (65)
cussed during handovers.
Handover location

Phase 6: Evaluation Outcomes Desk 4 (8)

Three months following eMDS implementation 35 (56%) nurs- Bedside 40 (82)
ing TLs completed a survey assessing their perceptions of the
Missing 5 (10)
eMDS (Table 3). Most respondents were female and had exten-
sive ICU experience. Handover tools used
Although all TLs giving handover carried out bedside han- during handover
dover (100%, n = 35) and used the eMDS (74%, n = 26), eMDS 42 (86)
enabling them to share the upcoming patient plan and give
Body systems paper 7 (14)
advice to oncoming TLs, they did not consider handovers were handover form
succinct or the forum to include patients or families. TLs receiv-
ing handover generally perceived handover positively reporting Ward view (computer 6 (12)
program)
that they felt comfortable asking questions, information was up
to date, timely, and contained sufficient content (Table 4). Other 11 (22)
TLs described advantages and disadvantages to using the Own notes 9 (18)
eMDS and suggested improvements. Responses provided three
or more times by TLs are reported. Seventy-one percent (n = Medical notes 1 (2)
35) of respondents surveyed described the advantages to be Unknown 1 (2)
content (48%), suitability for short-term patients (16%), saves
time (12%), and easy to print (12%).
Thirty (86%) respondents surveyed recalled disadvantages
to using the eMDS. Almost half of the participants found the
tool contained irrelevant information (e.g., number of times documented and missing and six (20%) nurses continued to
dialysis stopped and started), reported difficulties navigating write their handover notes.
and locating relevant information and missing content because Although several strategies were recommended, the most
items had not been autopopulated into the tool. In addition, common related to the layout of the eMDS (24%), using the
TLs found the eMDS time consuming (37%), difficult to print body systems to structure the tool (14%), incorporating the
(23%), the eMDS relied on medical notes that were often not typed weekly medical summary (14%), and reporting trends

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Table 2. TLs’ Use of the eMDS for Handover (N = 49) Table 2. Continued

Category Subcategory Frequency (%) Category Subcategory Frequency (%)

Unit flow and Mentioned in handover 31 (63) Observations 88 (27)

management
Recommendation Patient plan 232 (72)
Unit overview template 3 (6)
Chores for next shift 69 (21)
Equipment issues 10 (20)
Consultations 36 (11)
Identify Name 304 (94)
Other Alerts 82 (25)
Age/date of birth 252 (78)
Additional patient updates 56 (17)
Days in intensive care 237 (74)
a
Stated the body system before discussing observations.
Medical identification 2 (1) b
Discussed observations relating to the corresponding body system.
number
Bed number 138 (43)
Admitting doctor 138 (43) Table 3. Postimplementation Survey Respondent
Characteristics (N = 35)
Situation Diagnosis 186 (58)
Reason for admission to 239 (74)
ICU
Demographics Frequency (%) Median IQR
Surgical procedure 236 (73)
(if applicable) Gender

Acute resuscitation plan 18 (6) Male 5 (14)

Discharge status 85 (26) Female 24 (69)

Background Medical/surgical history 262 (81) Age

Patient issues/status 263 (82) ࣘ25 1 (3)

Management of issues 252 (78) 26–35 13 (37)

Assessment 36–45 8 (23)

Central nervous a
Acknowledged 75 (23) 46–55 10 (29)
system >55 1 (3)
b
Observations 283 (88) Nursing grade
Respiratory Acknowledged 67 (21) Grade 5 Registered nurse 23 (66)
system
Grade 6 Clinical nurse 8 (23)
Observations 295 (92)
Work status
Cardiovascular Acknowledged 81 (25)
system Full time 15 (43) 34 hr/week 6

Observations 289 (90) Part time 19 (54)

Gastrointestinal Acknowledged 24 (7) Number of years nursing

system ࣘ5 2 (6)
Observations 201 (62) 6–10 8 (24)
Renal system Acknowledged 19 (6) 11–20 10 (29)
Observations 252 (78) ࣙ21 11 (31)
Skin system Acknowledged 27 (8) Years working in ICU 13 7
Observations 98 (30) Year working as TL 8 5
Social system Acknowledged 6 (2)
(Continued)

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Table 4. TL Perceptions of an eMDS for Handover (N = 35)

Question Median IQR

TL receiving handover
I am able to ask questions about information that has been provided to me at handover 6 1
I am provided with sufficient information about patients at handover 6 0
The format in which information is provided to me at handover is easy to follow 5 3
The information that I receive is up to date 6 1
I am able to remain focused at handover 5 2
I am informed about different aspects of nursing care during handover 6 0
Patient information at handover is provided in a timely fashion 6 1
I feel that important information is not always given to me at handover 4 2
I am given information during handover that is not relevant to patient care 5 2
I can obtain the handover information from the patients’ electronic record instead of using the TL 5 2
handover tool
I find it beneficial to visualize the patient during handover 5 3
The information that I receive at handover is ambiguous? 3 2
The new handover tool extends the time needed for handover 5 2
TL giving handover
The new handover tool helps me to deliver a succinct handover 3 3
I feel comfortable handing over confidential information at the bedside 3 3
I use strategies to appropriately discuss sensitive information at handover 6 1
I am often interrupted by colleagues, patients and/or their significant others during handover 5 4
I have the opportunity to debrief with other colleagues at handover when I have a difficult shift 4 4
I have the opportunity to discuss how patient issues were managed during the shift 5 2
I have the opportunity to discuss workload issues at handover 5 3
I share the upcoming plans for patient care during handover 6 0
I give advice to the oncoming TL during handover 6 1
I invite patients to participate in the handover process 2 2
I invite family members to participate in the handover process 2 3
There is enough time for me to deliver handover 4 4

Note. 1 = Strongly disagree, 2 = Disagree, 3 = Somewhat disagree, 4 = Neither agree/disagree, 5 = Somewhat agree, 6 = Agree, 7 = Strongly agree.

in data such as vital signs rather than a snapshot at one point experienced ICU nurses. Multiple implementation strategies
in time (14%). (education, champions, reminders, ad hoc audit, and feedback)
were employed to overcome the barriers and complement
the facilitators identified in previous literature. Three months
DISCUSSION postimplementation, most TLs used the eMDS to conduct
Our study examined the implementation and evaluation of handover, however, key content items were absent and addi-
an evidence-based eMDS for ICU nursing TL shift-to-shift tional documentation was used alongside the eMDS. Nurses
handover using the KTA framework. Participants were receiving handover had more positive perceptions of the

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eMDS than nurses giving handover and open-ended questions Several benefits of incorporating information technology
revealed numerous disadvantages relating to the electronic into handovers have been described, however, our findings
capability of the tool and suggestions for improvement were were not consistent with the literature. Although the content
aimed at modifying the handover interface. of the eMDS was based on an earlier phase of this work, the CIS
Alongside identified deficiencies with the electronic han- was not able to accommodate some items into the handover
dover interface, the KTA framework lacked sufficient guidance interface such as trends in vital signs and specific therapies
to troubleshoot issues that arose during the implementation the patient received. Instead, the eMDS contained a snapshot
and evaluation process. The KTA is widely used in knowledge of vital signs at one point in time and contained all therapies
translation and is not only a process model (provides steps the patient received including unnecessary details such as the
in the process of translating research into practice), it is also a number of times a dialysis machine was stopped and started.
determinant framework (identifies the barriers and facilitators Consequently, TLs navigated through pages of information to
to implementation outcomes) that provides an implementa- locate pertinent items to discuss. A major limitation of current
tion process that proceeds in a step-wise linear fashion (Nilsen, ICU CIS is the inability to perform basic analyses (e.g., report
2015). The implementation process, however, is a multifaceted trends in vital signs) and future CIS will need to be able to
and complex phenomenon and the KTA has been criticized synthesize and translate data into meaningful, actionable in-
for being too generic, providing limited support during the formation (De Georgia, Kaffashi, Jacono, & Loparo, 2015). The
implementation process. eMDS did not include patient and family educational needs as
Although some improvements were seen in nursing TL this was conveyed by the bedside nurse. TLs discussed educa-
handover, our findings indicate that there were multiple short- tional needs if related to managerial issues.
comings with the implementation of an eMDS in the ICU. In
addition to using the KTA to structure the project, strategies Recommendations for Practice
informed by other theoretical approaches may have provided Several key considerations for the development of electronic
the researchers with additional support to resolve unantici- handover tools within CISs were identified in this study.
pated problems, thereby optimizing the knowledge translation Despite close collaboration between the researchers and CIS
process. The incorporation of strategies based on behavioral coordinator to resolve issues with the handover interface, the
theories such as the COM-B (Capability, Opportunity, Moti- infrastructure was inadequate to support the establishment of a
vation, and Behavior), which focuses on altering components handover tool that could meet end-user needs. Vendor support
of the behavior system to promote change (Michie, van Stralen, was critical to resolving the technological issues however would
& West, 2011) or the Transformation theory whereby clinicians have required additional funding that was not attainable or fea-
learn how their experiences, perceptions, and values lead to sible for this research study. Similar issues were highlighted in
subsequent actions by using critical reflection and discourse Saleem et al.’s (2015) study that evaluated commercial CIS for
(Matthew-Maich, Ploeg, Jack, & Dobbins, 2010) may have ICUs. The investigators suggested that efficient technical sup-
been a beneficial adjunct. Addressing emotions, attitudes, and port is needed to positively support the application’s reliability
beliefs toward an intervention may have motivated nurses to and end-user satisfaction (Saleem et al., 2015). Purchasing
embrace and sustain a new handover procedure. regional CIS that contain local or on-site technological support
Despite limitations of the KTA, several factors relating to the may provide ongoing and timely assistance rather than enter-
CIS may have also contributed to inadequate communication prise level CISs, where support is provided off-site, is either
of content items during TL handover. For instance, most TLs delayed or unavailable and frequently expensive to obtain.
printed additional documentation to accompany the printed When purchasing a CIS, organizations need to ensure that
eMDS as important information was absent either because the system can integrate data from multiple sources, the archi-
medical staff had not updated the electronic record (e.g., ad- tecture facilitates complex data mining and analysis (to make
mission notes) or because the CIS was unable to integrate infor- sense of patient data), incorporates a user friendly visual dis-
mation (X-ray and magnetic resonance imaging results) from play, and an interface that will promote informed decisions
external sources. A survey conducted by the Healthcare Infor- about patient care and the delivery of quality care to patients
mation and Management Systems Society reported that more (De Georgia et al., 2015). When developing and implementing
than 90% of hospitals used six or more types of medical devices electronic handover tools, it is vital to work with a skilled infor-
or databases and approximately one third integrated with one mation technology team to build a flexible interface that can be
another or the electronic medical record (Healthcare Informa- modified to accommodate user needs and meet national and
tion and Management Systems Society, 2010). Furthermore, local standards.
nurses were forced to print the eMDS for each patient as Wi-Fi
was unavailable to accommodate portable devices. Nurses re- Limitations of the Study
ported delays of up to 2 hr to upload and print eMDSs. Similar The study was conducted in one ICU, therefore the results
findings were identified in an examination of the use of an may not be generalizable but may be used to inform the
electronic handover tool to improve doctors’ weekend patient development of electronic handover tools in other ICUs,
handovers (Govier & Medcalf, 2012). especially given Australian ICUs are posited for wide spread

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use of MetaVision. It is possible nurses may have changed their Nursing (NCREN), Menzies Health Institute Queensland and
behavior during observational audits of handover, but several School of Nursing and Midwifery, Griffith University, Nathan,
observations of nursing handovers have been conducted previ- Australia, Intensive Care Unit, Princess Alexandra Hospi-
ously in the ICU for research and hospital-wide auditing and tal, Woolloongabba, Australia, and School of Health Sci-
the investigators believe that nurses appeared comfortable be- ences, City, University of London, London, United Kingdom;
ing observed. Wendy Chaboyer, Professor of Nursing, National Centre of
Research Excellence in Nursing (NCREN), Menzies Health In-
CONCLUSIONS stitute Queensland, Griffith University, Gold Coast, Australia
Our research examined the implementation and evaluation The investigators would like to thank Mary Wheeldon, Leanne
of an eMDS for nursing TL handover in the ICU. The KTA Parsons, Amanda Corley, Nicola Sharpe, Stephanie Dixon-
framework provided a structure to implement and evaluate an Horler, Megan O’keefe, Allison Wallace, Barbara Taylor, Elena
evidence-based eMDS for nursing TL shift-to-shift handover. Hergott, Deepa Joy, India Lye, Daniel Mullany, Marc Ziegen-
The incorporation of theories to challenge engrained attitudes fuss, and medical and nursing staff from the ICU for their
and behaviors may assist researchers and clinicians with em- support, encouragement, and participation in this project.
bedding evidence into clinical settings such as the ICU. Al- This work was supported by the Babe Norman PhD Scholarship
though interest in eMDSs is gaining momentum in healthcare awarded by the Nurses Memorial Centre.
facilities, adequate infrastructure is required prior to devel- Address correspondence to Amy J. Spooner, Nursing and
oping electronic interfaces in healthcare settings. Electronic Midwifery Research Centre, Royal Brisbane and Women’s
handover interfaces need to be flexible, modifiable, easy to nav- Hospital, Brisbane, Building 34, level 7, Queensland 4029,
igate, contain content that promotes succinct and informative Australia; [email protected]
handovers of ICU patients to maintain continuity of care and
Accepted 4 November 2017
improved patient outcomes. WVN
Copyright 
C 2018, Sigma Theta Tau International

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