Effect of Management Intervention Program on Intensive Care Unit Staff Nurses’ Shift Change Process at El Menshawy Hospital

Background: Shift change is a nursing care process, and communication core element in this process especially during the transfer of information. Steps of shift change process include identification, situation, background, assessment and recommendation play an important role in transferring responsibility and accountability in patient care from outgoing shifts to incoming shifts. Unfortunately shift change shift change education still nonexistent or inadequate. Objective: The aim of study was to determine effect of intervention management program on ICUs staff nurses’ shift change process at El Menshawy Hospital. Method: Design Quasi-experimental research design was used Setting The study was conducted in all intensive care units (ICUs) of El Menshawy General Hospital. Subject: consisted of all (n=164) nurses working in ICUs. Tools: Two tools were used for collecting data (1) Structure Knowledge Questionnaire (2) Staff Nurses Perception about Shift Change Process Performance. Results: staff nurses 95.1% had poor level of knowledge and 72.0% of staff nurses had low level of perception about shift change process performance. Post management intervention program staff nurses 70 %, 83.5% showed overall knowledge and high level of perception about performance of shift change respectively. There was statistically significant positive correlation between staff nurse total knowledge and perception of all dimensions of shift change process preprogram and post program at (p=0.001). Except task management dimensions showed no significant correlation. Conclusion: Staff nurses required to communicate accurate and concise information, which can be easily understood by both the outgoing nurse and the incoming to ensure the continuity and safety of patient care. Recommendation: Staff nurses need restrict supervision and motivation by head nurses for performing shift change process.


Introduction
Shift change is a fundamental routine clinical practice for the effective transfer of patient care plan between health professionals.Nursing shift change represents one of the most important transition points for responsibility and accountability in patient care among nurses When a patient was 'handed over' by an outgoing nurse to an incoming nurse between shifts, communication about the patient's condition was important to ensure appropriate continuity of care (1) .Failure to understand a patient's condition, put the patient at risk.In particular failure of dire events, delayed treatment might caused by nurses' failure to share all relevant clinical information of the patient accurately and timely.Often shift change consists of a range of vital information like the patient's diagnosis and treatment plan (2) .Clinical nursing shift change process was a routine yet pivotal, high-risk communicative event require cooperative teamwork, prioritization of activities and good work atmosphere.Nurses' formal shift-end shift change s occurred at least three times a day, excluding the inbetween breaks or patient transfer (3) .Shift change communication protocols are designed to help nursing staff to structure their shift change communication and present patients' information in a logical and coherent manner, with the aim of reducing the possibility of miscommunication or misunderstanding between the nursing professionals.Bedside, shift change provides an important opportunity for development of communication between nurses and patients and also their relatives (4) .Patients in critical care are severely ill and require support for vital functions.These patients are often sedated and their communication impaired.They can be vulnerable because of their inability to protect their integrity and autonomy.Patients are transferred to critical care units from various other care settings such as the resuscitation room, surgery or other wards.When a patient is transferred between hospital settings shift change report is given to staff in the new setting (5)   .Effective and accurate communication between nurses during shift change therefore critical in ensuring safe and consistent quality of healthcare.Shift change ensured patient security, increased efficiency, and contributed to the development of team work along with patient centered care.On the other hand, shift change increased work satisfaction, interpersonal relationships, and sense of responsibility while contributing to the acquisition of patient information and the decrease of overtime rates (6) .Intensive and critical care teamwork strive to entail cooperation, coordination and absence of conflict to protect patients' integrity and autonomy while providing care for their medical concerns.They perceived shift change as a unique opportunity to get to know the patient as a person, which is often difficult as many patients are unconscious on admission (7) .Person centered care is an internationally known framework through which a health professional establishes a therapeutic relationship to a person, emphasizing values respect for the person and mutual understanding.Getting to know the person is considered vital to person-centered care, which places patient in context and fulfils that person's best interests (8) Significance of study Currently, clinical environments are dynamic and complex, presenting many challenges for effective shift change among health care providers.This demands efficiency during shift change process that compromise information exchange, the care for each patient demands an immediate knowledge of critical and highly complex data.So, present study management intervention program is needed for ICUs incoming and outgoing nurses to improve their knowledge and practice for promoting safe, effective, comprehensive and highquality transitions of patients' care information during shift change process (9) .

Aim of the study
The study aimed to determine effect of intervention management program on ICUs staff nurses' shift change process at El Menshawy Hospital.

Research hypothesis
After implementation of the intervention management program the knowledge and perception of ICUs staff nurses during shift change process expected to be improved.

Subjects and method
Study design: Quasi-experimental research design Setting: The study was conducted in all intensive care units at El-Menshawy General Hospital, which affiliated to Ministry of Health and Population.The total hospital capacity contained (300) beds, it divided into outpatient clinics and inpatient units as well as ICUS including Pediatric ICU (5 beds), Cardiac ICU (15 beds), Neonate ICU (27 incubators), Neuro ICU (3 beds), and Medical ICU (17 beds).

Tools of data collection
The data of the study collected using two tools: Tool 1: Structure Knowledge Questionnaire This tool was developed by the researcher guided by Ewing (2015) (10) , Halm (2013) (11)  The tool developed by the researcher guided by Manser and Foster (2011) (12) and related recent literature.This tool used to assess staff nurses' perception on shift change process.General Hospital administration permission to conduct the study and get approval and assistance to collect data from staff nurses.2-Ethical considerations: the study aim was explained to staff nurses to gain their cooperation, verbal consent for their participation in the study was obtained and they had the right to withdrawal.They were informed that their information was kept confidential.3-Tool 1,2 was developed by researcher and translated and presented to a jury from the area of specialty to check tool content validity.They were seven assistant professors from Faculty of nursing, Tanta university (four from nursing service administration department, two from medical department and one from psychiatric nursing department).4-The jury responses were represented in relevance score ranging from 1-4 Strongly relevant=4, relevant=3, little relevant=2 and not relevant=1.Necessary modifications were done included clarification, omission of some questions and adding others and clarifying words.The content validity for tool 1 was tested using Chi-Square test and for tool 2 was tested using Wilcoxon signed rank test 5-Reliability of tool 1 and 2 tested using Cronbach Alpha Coefficient test and its values 0.886 and 0.774 respectively.6-A pilot study was carried out on 10% (N=17) nurses and they were excluded from the study subjects.It conducted to test the tools for its clarity, feasibility, applicability, relevance of the questions, and to determine the needed time to complete the questionnaire.A pilot study was carried out after the experts' opinion and before starting the actual data collection.According feedback from pilot study, some questions were rearranged by the researcher to be easily understood.The estimated time needed to complete the questionnaire items from nurses was 20-30 minutes for every tool.The table shows that there was highly statistically significant improvement of staff nurses communication subscale post than preprogram.Staff nurses 88.4%, 81.1%, 67.7% and 54.9% preprogram showed low level of perception about performing interaction and support, patient involvement, quality and quantity of information and efficiency dimension respectively.While, post program staff nurses 89.6%, 53.0% and 48.8% showed high level of perception about performing quality and quantity of information, interaction and support and patient involvement respectively.Except 64.6% showed moderate level and 25.0% showed high level of perception for efficiency post program.Elhanafy & Hammour, (2017) (13) study about effect of educational sessions about effectiveness of handoff system for nurses on their knowledge and practice, support present study and found inadequate patient information during shift change which carries significant risks for nurses, patient and their organizations.So sufficient and relevant information through educational sessions should be exchanged to ensure patient safety and continuity of care.Moreover, without handoff education, the nursing students in this study lacked awareness of the importance and benefits of handoff, methods of handoff as well as components of handoff and communication.But significant difference in nurses` handoff knowledge discovered between pre and post nurses educational sessions.Dunn (2017) (14) study about trust wide clinical division policy document clinical handover at nurse shift change also states that a standard shift change implementation is required to ensure the smooth transfer of information, care and management of the security of patients in ICU.Shift change steps are essential so that the shift change process is more effective, efficient, consistent, and ensures smooth delivery of information and safety of patient care.Also Shahid & Thomas (2018) (15) study about situation, background, assessment, recommendation communication tool for handoff in health care in the background step, found that lack of understanding of shift change steps of process implementation lead some nurses to face confusion when communicating supporting clinical conditions.Nurse should communicate patient background and problems, including explaining the actions taken for every patient's nursing problem, history of allergy and surgery, installation of invasive devices, administration of drugs and intravenous fluids, as well as the results of identification of the patient's knowledge of their illness.Based on the study the majority of nurses were in the poor level of knowledge about background information due to failing to mention that patient had an allergy and not reported any installation of invasive devices, administration of drugs and intravenous fluids resulting in suboptimal reporting.Preprogram three quarter of staff nurses showed low overall perception about shift change process.Specially the dimensions of situation awareness, communication and circumstances of shift change.They showed low quality and quantity of information, low interaction and support as well as low efficiency and patient involvement.Beside those staff nurses were not aware of their role at the beginning of shift change and they ensure that they never feel having positive effect from the process of shift change.Adding to their poor overall knowledge about shift change process.Apparently head nurses' supervision are required to improve those staff nurses' motivation, spirit and for better performance of safe shift change activities.While they need periodical training programs to improve their shift change knowledge and performance.Manias et al (2017) (16) study multisite survey a cross different health professionals, found that inadequate shift change communication and documentation puts patients at increased risk for adverse events because of delays in treatment or procedures.Also the potential impacts of lack of crucial information during shift change may be felt at number of levels including inadequate and inappropriate care resulting in patient harm, and breach of safety and quality standards.The study recommended for improvement around the use of structured checklists, compliance with standards procedure and access to clarity of information.
Welsh et al (2019) (17) study about barriers and facilitators to nursing handoffs recommendations for redesign found the same result as the current study.Their analysis showed that inadequate information, inconsistence quality and limited opportunity to ask questions.Beside equipment malfunction, insufficient time to generate reports and lack of organization.Researchers also found complexity of patient's conditions, inadequate, disorganized coordination, poor or absent documentation of shift change and limited interruptions shift change communication.
Sitterding & Broome (2020) (18) study about understanding situation awareness in nursing work a hybrid concept analysis, found that student had a low level in the perception, comprehension and projection of situation awareness before receiving the training.In which they didn't have cues that trigger perception; visual, auditory or tactile which create the ability to detect and understand the different distinctions for example regarding patients' safety standards and handling system of the equipment The result of information gained by student nurse while they collect data about their assigned patients hadn't yet been reflected in their practice.
Streeter & Harrington (2021) (124)  Yet those staff nurses realize the importance of following the steps of shift change process and communication as well as trained on the skills required for incoming and outgoing staff nurses.Really that management intervention program increased their knowledge and perception regarding explaining treatment needed by the patient, endorsing services needed for the patient, providing relevant historical information about the patients, and answering the other nurse's questions thoroughly.In addition, during bedside shift change the outgoing staff nurse encouraging the incoming one to ask questions and seek information, answering questions of incoming staff nurse related to the patient's needs.As well as reviewing important or complex information to make sure it correctly understood and making sure that all explanations and directions were clearly understood.Seada & Bayoumy (2017) (20) study about effectiveness of handoff educational program on nurses' interns' knowledge, and communication competence, who found that there was statistically significant and marked improvement in nurses' levels of shift change knowledge dimensions during different periods of assessment for the majority of handoff knowledge dimensions.This finding matched with Thaeter et al. (2018) (21) study about handover training for medical students: a controlled educational trial of a pilot curriculum in Germany who showed that knowledge dramatically altered and improved following the handover teaching and training program, resulting in a decrease in information omission and improved handover quality.Soliman (2022) (22) study about effect of an educational program about intradepartmental communication among nurses on nurses' empowerment.The study revealed that there was a general improvement in nurses' knowledge, staff nurses surveyed having good knowledge of communication and reporting at the time of the immediate post-educational program assessment.In the same line Daniel &N-Wilfong (2022) (23)

Figure ( 2 ):
Figure (1): Shows levels of staff nurses' overall knowledge about shift change process pre-and post-program.Preprogram majority of staff nurses had poor level of knowledge for shift change process but post program the majority were at good level.Figure (2): Shows levels of staff nurses' knowledge about steps of shift change process pre-and post-program.Preprogram majority of staff nurses had poor level of knowledge about steps of shift change process but post program the majority were at good level.Figure (3): Show levels of staff nurses' overall perception about shift change process pre-and post-program.Preprogram majority of staff nurses had low level of total perception about shift change process but post program the majority were at high level.Figure (4): Show levels of staff nurses communication about shift change process.Preprogram majority of staff nurses had low level of communication about shift change process but post program the majority were at high level.Figure (5): Show levels of staff nurses teamwork about shift change process.Preprogram majority of staff nurses had

Figure ( 3 ):
Figure (1): Shows levels of staff nurses' overall knowledge about shift change process pre-and post-program.Preprogram majority of staff nurses had poor level of knowledge for shift change process but post program the majority were at good level.Figure (2): Shows levels of staff nurses' knowledge about steps of shift change process pre-and post-program.Preprogram majority of staff nurses had poor level of knowledge about steps of shift change process but post program the majority were at good level.Figure (3): Show levels of staff nurses' overall perception about shift change process pre-and post-program.Preprogram majority of staff nurses had low level of total perception about shift change process but post program the majority were at high level.Figure (4): Show levels of staff nurses communication about shift change process.Preprogram majority of staff nurses had low level of communication about shift change process but post program the majority were at high level.Figure (5): Show levels of staff nurses teamwork about shift change process.Preprogram majority of staff nurses had

Figure ( 4 ):
Figure (1): Shows levels of staff nurses' overall knowledge about shift change process pre-and post-program.Preprogram majority of staff nurses had poor level of knowledge for shift change process but post program the majority were at good level.Figure (2): Shows levels of staff nurses' knowledge about steps of shift change process pre-and post-program.Preprogram majority of staff nurses had poor level of knowledge about steps of shift change process but post program the majority were at good level.Figure (3): Show levels of staff nurses' overall perception about shift change process pre-and post-program.Preprogram majority of staff nurses had low level of total perception about shift change process but post program the majority were at high level.Figure (4): Show levels of staff nurses communication about shift change process.Preprogram majority of staff nurses had low level of communication about shift change process but post program the majority were at high level.Figure (5): Show levels of staff nurses teamwork about shift change process.Preprogram majority of staff nurses had

Figure ( 5 ):
Figure (1): Shows levels of staff nurses' overall knowledge about shift change process pre-and post-program.Preprogram majority of staff nurses had poor level of knowledge for shift change process but post program the majority were at good level.Figure (2): Shows levels of staff nurses' knowledge about steps of shift change process pre-and post-program.Preprogram majority of staff nurses had poor level of knowledge about steps of shift change process but post program the majority were at good level.Figure (3): Show levels of staff nurses' overall perception about shift change process pre-and post-program.Preprogram majority of staff nurses had low level of total perception about shift change process but post program the majority were at high level.Figure (4): Show levels of staff nurses communication about shift change process.Preprogram majority of staff nurses had low level of communication about shift change process but post program the majority were at high level.Figure (5): Show levels of staff nurses teamwork about shift change process.Preprogram majority of staff nurses had

Figure ( 1
Figure (1): Levels of staff nurses' overall knowledge about shift change process pre-and post-program (N=164) study about empowering interprofessional teams to perform effective handoffs through online hybrid simulation education, found that participants' knowledge of shift change communication improved after the educational program.The present study highlighted that the implementation of current management intervention program about shift change process succeeded as mean for improving staff nurses knowledge and perception about performance.The intervention assisted those staff nurses to perform their effective shift change process significantly positively different from program.Therefor Elmenshawy Hospital need to take serious actions to provide support and resources for staff nurses in the form of educational and training intervention opportunities.Such intervention better to be designed periodically to improve and update their knowledge, perception and performance about shift change process.ConclusionResult shows low level of staff nurse's knowledge about shift change process and low level of their perception about performance.This reflects staff nurses demand to educational intervention program about shift change process.Specially they required to have information and performance of dimensions of shift change process including communication, teamwork, situation awareness, task management, accountability and responsibility as well as circumstances of shift change.The present study well designed program improved staff nurses' knowledge and perception about performance of shift change process.Implementation of shift change process program in ICU is important for its positive impact on information exchange.Nurses need to communicate accurate and concise information, which can be easily understood by both the outgoing and the incoming staff nurses to ensure the continuity and safety of patient care.Recommendations are suggested 1-Staff nurses need restrict supervision and motivation by their head nurse for performing of shift change process.2-Nurse shift change process should be made part of the training curriculum for nursing students in order to improve their knowledge and performance.3-There is need for regular updates selflearning knowledge among staff nurses to enable them to acquire special skills that will enhance better communication during shift change process.
The age, gender, marital status, education level, years of experience as well as training program were included.The age of staff nurses ranged from <30-≥35 years with mean age 28.80 ± 3.71.Staff nurses 81.7% were female, married 75.0% and 25% single.Bachelor degree nurses were 69.5% and 8.5% had master degree.High percent 71.3% of staff nurses had <10 years of experience in the unit with mean experience 6.27 ± 3.98 years.

Table (
4-Staff nurses should follow standard for shift change process in order to improve their performance.5-Staff nurses should know that proper shift change process consider their tool to transfer responsibility and accountability of patient care.6-Periodical training educational intervention programs required for staff nurses.7-Staff nurses required to communicate accurate and concise information to be easily understood by both the outgoing and the incoming staff nurses to ensure the continuity and safety of patient care.8-Staff nurses required to ensure transfer of