Nurses shift handover is a delegation of authority and primary responsibility in providing care to patients between shifts at the hospital. The activity in the handover is to submit a report on the condition of the patient based on nursing care carried out by the nurse during her work hours.
The purpose shift handover is to provide accurate information about the patient’s care plan, nursing actions that have been taken, therapies that have been given to patients, the latest conditions, changes that will occur and anticipation and follow-up nursing plans that will be carried out by the next shift nurse. The process of delivering patient condition information between nurse shifts is very important and must be continuous, so nurses need special instruments that can facilitate the process of delivering effective and efficient information.
According to the results of research at Surabaya Hajj Hospital regarding handover instruments of nurses shift with SBAR effective communication approach in the inpatient room, modifications are needed to facilitate the implementation of handover adjusting to the latest hospital accreditation standards. The development of instruments in the research conducted at the Surabaya Hajj Hospital was based on effective communication from SBAR method, accommodating National Hospital Accreditation Standards (SNARS), prioritizing patient safety, focusing on the quality of nursing services, and integrating technology and information developments.
SBAR stands for situation, background, assessment, recommendation, which is a technique or method that can be used to facilitate effective, fast and appropriate communication. This communication is increasingly popular in the field of health services, especially among professionals, for example, between the medical professionals, nursing, oral counsel or reporting critical conditions of patients. The use of the SBAR format will help nurses focus on important aspects that will be shared with colleagues during the handover process so it can be more effective and efficient.
Situation is the most recent condition that occurs in patients. Situation contains patient data including patient name, date of birth, date of admission, day of care, responsible doctor, responsible nurse, room name, bed number, reason for hospital admission, medical diagnosis, nursing problems and patient’s main complaints.
Background explains the patient’s condition in full. The nurse will mention the history of the disease and previous treatment, a history of allergies, laboratory results, rontgent results, treatments and nursing interventions that have been carried out and the patient’s response to care and treatment measures. Assessment is an assessment of the patient’s current condition. The information includes vital signs (temperature, blood pressure, frequency of respiration), level of consciousness, perceived pain, nutritional status (weight, height, body mass index), ability to defecate and urinate, presence of wounds in the body (especially pressure sores) and other supporting clinical information. Recommendation informs nursing actions that should be based on situation, background, and assessment data including action plans to be taken, follow-up plans, solutions that nurses can offer to doctors, what nurses need from doctors to improve the patient’s condition, and time the nurse expects when the action occurs.
This handover instrument with SBAR method enhances the nurse’s ability to identify patients’ complaints and conditions quickly and systematically so that a solution is immediately provided to overcome these problems in the form of appropriate care and treatment based on patient complaints. Furthermore, it makes it easy to deliver information between nurses and other health teams who also treat patients, such as doctors, pharmacists, and nutritionists. The use of appropriate instruments improves the quality of nursing services and has an impact on patient satisfaction while being hospitalized. (*)
Author: Dr. Rizki Fitryasari PK, S.Kep.,Ns.,M.Kep (Fakultas Keperawatan Unair)
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