Communicating Safely: Standardizing Nursing Clinical Reports in a Neonatal Unit.

Abstract

Background: Clinical documentation during nursing handovers is critical for safe neonatal care. Poorly structured or inconsistent documentation can lead to miscommunication, delayed interventions, and fragmented care. A 2021 audit in a tertiary neonatal unit revealed only 2% of nursing handover reports followed the recommended Introduction, Subjective, Objective, Assessment, Plan (ISOAP) format, posing significant risks to patient safety.

Purpose: This quality improvement initiative aimed to improve compliance with ISOAP documentation format for nursing handovers in a tertiary Neonatal Intensive Care and Special Care Nursery (NICU/SCN), addressing both paper-based and digital systems.

Methods: A 3-year quality improvement project was conducted using the Institute for Healthcare Improvement's Model for Improvement. Two Plan-Do-Study-Act (PDSA) cycles were implemented. PDSA Cycle 1 focused on paper-based documentation, while PDSA Cycle 2 targeted Digital Health Records (DHR). Interventions included the development of neonatal-specific ISOAP templates, education sessions, peer mentorship, visual reminders, and ongoing staff support. Compliance was measured through pre- and post-intervention audits.

Results: Baseline adherence was 2% in February 2021. Following PDSA Cycle 1, adherence rose to 78% by January 2022 and reached 100% by March 2022. During the DHR transition, adherence improved from 65% in May 2023 to 92% by July 2023. Staff reported improved clarity, enhanced communication, reduced time required for clinical reviews, and greater satisfaction with documentation processes.

Implications for practice and research: Structured education, standardized templates, and peer support effectively improved documentation compliance. Future research should explore the impact of standardized handover documentation on neonatal outcomes and further strategies for optimizing digital implementation.