Reporting and Transitions in Care

This edition of the Standards in Focus highlights the Standards of Practice and Conduct that address the safe transfer of responsibility and accountability for client care from one provider to another, often referred to as reporting, handover, or transition in care. This article will allow you to reflect on how you apply the standards in your practice. ¹

Category five (V) of the Standards is focused on collaborative care and states that licensed practical nurses practice in partnership with clients and a team of health care providers using a participatory, collaborative, and coordinated approach.

The Standards related to transitions in care state that, as an LPN, you must:

• Plan and facilitate the safe transition of clients between caseloads, practitioners, settings, and services. (Standard 43)  
  
• Choose effective communication tools and techniques that facilitate discussions and interactions that enhance team functioning. (Standard 48)

• When involved in providing for the health care of a client:
  • Work collaboratively and cooperatively with the client, their family, and other health care providers, and communicate effectively and appropriately with them, to facilitate the client’s health care.
  • Ensure that you understand your role and the role of other health care providers in providing for the client’s health care. (Standard 49)

The entry-level and full competencies for the profession also lay out expectations for transitions in care. ² Examples of competency statements include: 

• Initiates collaboration to support care planning and safe, continuous transitions from one healthcare facility to another, or to residential, community or home and self-care.
• Integrates evidence-based practice initiatives into the practice environment in collaboration with members of the health care team.

To read more on the competencies, please visit:

CLPNM Entry-Level Competencies

Risk and Transitions in Care

As health knowledge and types of service delivery expand, so do the complexities of transitions in care between providers. A transition in care involves transferring information, responsibility, and accountability for client care from one provider or team to another. Sharing relevant client care information between providers is integral to safe health care delivery. ³  Inadequate reporting during transitions in care in a known risk to client safety. ³ 

The complex nature of transitions in care introduces the potential for problems such as communication breakdown. A communication breakdown can cause gaps in health care provision and impede the therapeutic trajectory for a client. Risk factors for communication breakdown during transitions in care include:

• A physical work environment that is noisy and prone to interruptions or distractions. ³
• A report conducted under physical or emotional pressure. ³
• The omission of essential information. ³

An effective transition in care report involves receiving clarification and confirmation of critical information and the opportunity to ask questions, thus enabling continuity of client care and treatment. ³

For effective reporting during a transition in care, a standardized process to guide the transfer of information is recommended to mitigate risks of communication breakdown. ⁴ In particular, protocols or tools that include phonetic and numeric clarifications and reminders can support accurate information transfer. One such tool is the ISBAR tool (identify, situation, background, assessment, recommendation). ⁴

Nursing Practice Scenario

Mrs. Zin, an 82-year-old female, is a client in a sub-acute medical unit in a tertiary hospital. Florentina, LPN is Mrs. Zin’s nurse today.

Florentina performs a head-to-toe assessment, including the Glasgow Coma Scale (GCS), on Mrs. Zin. The vital signs (VS) are blood pressure 168/46, pulse 76, respiratory rate 20, oxygen saturation 95% on room air, and temperature 36.7. Mrs. Zin has a left-sided weakness, left facial droop, left-sided neglect, and visual field disturbances. Florentina notices the bruising on Mrs. Zin’s left hand, and Mrs. Zin’s daughter-in-law informs Florentina that Mrs. Zin has just finished having a nosebleed. Florentina knows that Mrs. Zin’s INR was 2.2 yesterday, and the Coumadin was withheld. Florentina is aware that today’s blood work has already been drawn, and she will watch for the results.

Through the assistance of her daughter-in-law, Mrs. Zin requests to go to the washroom. Florentina provides her with the wheeled walker and assists her. Mrs. Zin’s left-sided weakness is evident during ambulation. After going to the washroom, Florentina takes Mrs. Zin for a walk down the hallway. When breakfast trays are delivered, Mrs. Zin’s daughter-in-law helps Mrs. Zin with breakfast while Florentina prepares 0900 medications.

While Florentina is administering her medications, the rehabilitation unit nurse calls for a report on Mrs. Zin. Although this is Florentina’s first shift with Mrs. Zin, Florentina has read through Mrs. Zin’s chart, reviewed all the bloodwork, the diagnostic tests performed, the medication administration record, vital signs, consults with other disciplines and conducts a head-to-toe assessment of her client. Florentina is ready to communicate a complete report that will ensure client safety and continuity of care.

The unit that Florentina works on has recently implemented the ISBAR (identify, situation, background, assessment, recommendation) communication tool. Florentina prepares to report to the receiving nurse using the ISBAR tool as follows:

I	I am Florentina, LPN, from 6 North, calling to give report on Mrs. Zin, who will be transferred to bed 36-2 in the rehabilitation unit.
S	Mrs. Zin is an 82-year-old female admitted to 6 North 7 days ago with a right-sided cerebral vascular accident (Rt CVA).
B	Mrs. Zin had a Rt CVA and has a residual left-sided weakness, left-sided neglect, left visual field disturbances, and some behavioural inappropriateness. Past medical history includes hypertension, cardiovascular disease, and an old fractured right tibia. She has an allergy to Penicillin and is on a pureed diet. There is a language barrier, as Mrs. Zin speaks only Cantonese, and family who are here 24 hours interpret.
A	VS done this morning – blood pressure 168/46, pulse 76, respiratory rate 20, oxygen saturation 96% room air, temperature 36.8. Yesterday’s blood work – hemoglobin is 126, WBC 5.1, and INR 2.2. Coumadin was withheld yesterday and is on hold to be reassessed with today’s blood work, which has already been drawn. GCS is 14. Mrs. Zin had a nosebleed this morning per family and has a bruise on her left hand. According to the family, Mrs. Zin is intermittently confused, which is not new. She ambulates with her walker and a one-person assist. I walked with her this morning, and she tolerated this well.
R	INR is to be maintained at a therapeutic level, and the doctor is to be notified of today’s INR. Mrs. Zin is to ambulate three times a day with her walker and a one-person assist. Occupational and physical therapy are both consulted and aware of her being transferred. They are assessing to determine what assistance devices Mrs. Zin requires due to her left-sided weakness. Home Care has been consulted but has not yet seen Mrs. Zin, so you may need to remind them. The discharge plan is to return to the family home with her son and daughter-in-law.

In this scenario, Florentina upheld Standard 43 – Plan and facilitate the safe transition of clients between caseloads, practitioners, settings, and services. She planned and facilitated the safe transfer for Mrs. Zin by preparing pertinent information to communicate to the receiving nurse to ensure client safety and continuity of care.

Florentina also upheld Standard 48 – Choose effective communication tools and techniques that facilitate discussions and interactions that enhance team functioning by choosing the ISBAR, an evidenced-based communication tool.

Finally, Florentina upheld Standard 49 – When involved in providing for the health care of a client: (a) work collaboratively and cooperatively with the client, their family, and other health care providers, and communicate effectively and appropriately with them, to facilitate the client’s health care, and (b) ensure that you understand your role and the role of other health care providers in providing for the client’s health care. Florentina used the ISBAR communication tool to facilitate discussion with the receiving nurse, communicated effectively, collaborated, and worked cooperatively with the client, family, and other healthcare providers for the client’s healthcare.

While upholding the Standards of Practice and Conduct, Florentina also demonstrated the following entry-level competencies related to transitions in care:

• Initiates collaboration to support care planning and safe, continuous transitions from one healthcare facility to another, or to residential, community or home and self-care.
• Integrates evidence-based practice initiatives into the practice environment in collaboration with members of the health care team.

Reflective Exercises

Consider engaging in self-reflection about your reporting during transitions in care, and ask yourself the following questions:

• Am I always prepared to provide a thorough report that supports care continuity?
• Do I focus on client safety while reporting?
• Do I always provide pertinent information when reporting?
• Do I ever provide non-pertinent information?
• Can my reporting skills be improved?

Conclusion

Transitions in care are a known point of risk to client safety. The CLPNM Standards of Practice and Conduct expect LPNs to plan and facilitate safe client-care transitions between providers. As responsibility and accountability are transferred from one health care provider to another, important information for client safety and continuity of care must be transferred. One strategy to mitigate risk during transitions in care is using a reporting tool that includes phonetic and numeric clarifications and reminders. The ISBAR is one such tool. A well-executed transition in care report will mitigate risk factors and promote client safety and continuity of care.

Next month Your Standards in Focus will be on team dysfunction and conflict.

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References

1. College of Licensed Practical Nurses of Manitoba (2021). Standards of practice and conduct for Manitoba’s practical nurses.
   
2. College of Licensed Practical Nurses of Manitoba (2021). Entry-level competencies for the licensed practical nurse in Manitoba.
   
3. Friesen M, White S, Byers J. Patient Safety and Quality:  An Evidence-Based Handbook for Nurses. National Library of Medicine National Center for Biotechnology Information. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2649/
   
4. Moi E, Soderhamn U, Marthinsen G, Flateland S. The ISBAR tool leads to conscious, structured communication by healthcare personnel. 2019 Norsk. Available from: https://sykepleien.no/en/forskning/2019/03/isbar-tool-leads-conscious-structured-communication-healthcare-personnel
   
5. Muller M, Jurgens J, Redaelli M, Klingberg K, Hautz W, Stock S. Impact of the communication and patient hand-off tool SBAR on patient safety:  a systematic review. BMJ Open 2018;8e022202.