Running head: HANDOFF COMMUNICATION
Developing a Standardized Handoff Communication
Christine Peterson
Azusa Pacific University
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ERRORS IN PATIENT CARE RELATED TO POOR HANDOFF COMMUNICATION
The process of handoff report varies from hospital to hospital, floor to floor, and often
from nurse to nurse. Few hospitals today have a standardized shift report that every nurse uses.
Handoff report may take place in multiple locations, use multiple different tools, and vary in the
order it is given. Poor handoff reports have been found to be a significant cause of errors in
patient care. Developing a standardized handoff report may prove to reduce errors in patient car.
Current handoff environments vary and include hallways, nurses’ stations, and patient
rooms. The tools used in hand off reports may include patients’ electronic medical record,
nurses’ own SBAR forms, and blank pieces of paper. The people involved in this process are the
nurse from the previous shift and the nurse from the oncoming shift. Handoff reports may also
involve the patient and their families. Differing processes and orders of handoff reports
contribute to missed information and subsequent errors in patient care. The goal of this
intervention is to develop and implement a standardized handoff communication tool and
checklist for end of shift report. A standardized handoff routine will be implemented including
bedside report at every patient handoff.
Risk Analysis
In an article by Berkenstadt et al. (2008), the authors discuss a study implemented as a
result of an error in patient care. A patient who was admitted to a medical step-down unit
experienced severe hypoglycemia after receiving an incorrect insulin dose. Following this event
facts were collected regarding the event and how it occurred. The error identified was during
handoff report. The nursing handoff report took place at the nurses’ station as opposed to the
bedside, which was the hospital’s policy (Berkenstadt et al, 2008). The authors observed 224
nursing shift handoff reports and based on the analysis of the data collected along with structured
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interviews with senior nurses, developed a standardized handoff process. The intervention in the
study included a checklist and protocol for handoff and the use of simulation in order to practice
its proper use. The authors then observed handoff reports after and recorded their observations.
The results showed that after the intervention, “there was an increase during the handoff process
in the number of nurses indicating the patients’ names, ages, diseases, and the reasons for
admission” (Berkenstadt et al, 2008). Furthermore, there was an increase in nurses describing
events that occurred during the previous shift. There was also a 100% adherence to presenting
treatment goals for the next shift, as opposed to 88% before the intervention (Berkenstadt et al,
2008). In 2006, goal 2 of the Joint Commission was to “improve the effectiveness of
communication among caregivers”. In a review of sentinel events, the joint commission found
that from 1995 to 2006 the leading cause was poor patient handoff communication (The Joint
Commission, 2006).
Open communication between nurses and patients is an important factor in fostering a
safe patient care environment. Patient satisfaction with nursing communication may improve
patient disclosure and ensure a safer environment. In a study by Kimberly Radtke, the author
sought to determine if standardizing shift report would improve patient satisfaction with nursing
communication (2014). The study implemented a pilot bedside shift report process on a medical
surgical unit. The author noted that nurses voiced frustrations related to information that they
received during shift report. Getting a poor hand off report can make nurses feel behind before
they start their shift. Complaints by nurses that were noted in the study included, “I didn’t hear
that report,” and “Medications were not given,” The intravenous fluids weren’t right/ wrong
rate.” The study found that patient satisfaction in nursing communication rose from 75 to 87.6
percent (Radtke, 2014).
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The World Health Organization (WHO) suggests that organizations ensure health care
organizations implement a standardized approach to handoff communication between staff,
change of shift, and between patient care units during a transfer (2007). Furthermore, WHO
recommends that components that should be included in such standardized handoff
communication are the use of the SBAR, allocation of sufficient time, information about the
patient’s status, medications, treatment plans, advance directives, and any significant changes,
and finally, limiting the exchange to only what is necessary to provide safe patient care (2007).
WHO also suggests that hospitals utilize proper training on effective handoff reports to hospital
staff (2007).
Process Analysis
People
Materials
Patients
Nurses
Nurses own SBAR form
EMR
Errors in Pt Care
R/T poor handoff report
Effect
Hallway
No standardized handoff
Nurses Station
No organized process
Environment
Current Process
Figure I.
Poor handoff report has been found to contribute to errors in patient care. There are
several factors that contribute to poor handoff report. Figure I describes factors involved in
handoff report that may contribute to these errors. The current people involved in handoff
communication are the nurse from the ending shift, the nurse from the oncoming shift, and in
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certain circumstances, the patient and their families. Materials involved in handoff are the
electronic medical record and nurses’ own SBAR forms. Forms used by nurses may include a
nurses’ own developed format, a standard form developed by each unit, or a blank piece of
paper. Environments in which handoff communications occur are the nurse’s station, hallways,
and patient rooms. Finally, the current process varies from nurse to nurse and unit to unit. The
lack a standardized handoff routine and checklist contribute to patient care.
In examining the contributing factors in figure I, the nurses involved in the handoff report
as well as the process and environment have the greatest impact on the problem. Giving handoff
report at the bedside can improve handoff report as well as include an additional person, the
patient, in the process. Including the patient in the handoff communication allows them to be a
part of their care as well as fostering a trusting nurse/patient relationship. The handoff
communication tools such as the electronic medical record and report forms are one area in
which nursing staff has great control over. Working together, nursing staff can develop a
standardized form for handoff communication, which will improve the ease and effectiveness of
change of shift report.
According to the world health organization (2007) possible barriers to implementing a
standardized bedside report include resistance to change behaviors, time pressures, training and
cost of time to implement new processes, low health literacy, staffing shortages, and lack of
knowledge about how to improve systems. Another barrier to consider is that different units may
have different requirements for a standardized handoff form. Older units also do not have a
computer in the rooms, which may make it difficult to have the electronic medical record open
during report. It may be necessary to require nurses to bring a computer on wheels (COW) into
the room when they are giving handoff report.
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Recommendations for Change
Two theories described in Radtke’s study include Peplau’s interpersonal relations theory
and Lewin’s theory of changing practice. These theories point to the need for a change in
handoff communication practices to one that is done to involve the patient to enhance the
nurse/patient relationship as well as to improve its effectiveness and provide a safe patient care
experience.
Radtke describes Peplau’s interpersonal relations theory in her article (2014). Peplau’s
interpersonal relations theory describes nursing as therapeutic. He notes that while knowledge
and practice of nursing are important, they are secondary to interpersonal relations. Peplau
states, “Nursing is an educative instrument, a maturing force that aims to promote forward
movement of care” (Radtke, 2014). Nurse patient relationships is a vital part of the nursing
process and is necessary in assessing, planning, and intervening on behalf their patients.
Allowing for therapeutic relationships in nursing care is an important part of safe and effective
care. Providing bedside report helps to promote this therapeutic relationship and also builds
patient satisfaction with the nursing care. Providing a therapeutic relationship also helps the
patient to trust nursing staff and therefore allow for effective care. An effective bedside report
enhances trust, mutual understanding, open communication, and mutual goal setting (Radtke,
2014).
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Figure II.
Additionally, Radke describes Lewin’s planned change theory, which describes changing
practice as a daunting practice that includes a “realization that change is required and acceptance
that it can bring improvement” (Radke, 2014). The theory points out that change should be
instituted when there is a need for it to improve patient care, however it should not be instituted
simply for the sake of changing things. Instituting changes in shift report in order to ensure a
standardized bedside shift report can improve patient safety and care. Lewin describes change as
a process that involves an unfreeze, change, and refreeze. The change implemented in order to
better the healthcare environment should become permanent.
Figure III.
Klee, Latta, Davis-Kirsch, and Pecchia (2012) discuss the benefit of using continuous
performance improvement methodology in order to standardize nurse handoff communication in
order to improve patient safety, increase patient and family involvement, and decrease end-ofshift overtime. Continuous process improvement methodology (CPI) consists of discipline, daily
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practices, and tools that will help to establish and maintain improvement (Klee et al, 2012). By
the completion of the study 93% of nurses followed the standardized handoff sequence.
Standard nursing handoff communication will be given at the bedside. Nurses should
involve patients in the handoff report whenever possible. Nursing practice council will work
together to develop a standardized shift report form. Some forms may need to be specialized to
meet the needs of different departments, such as postpartum units. Each unit will have a
standardized report form to be utilized at each patient handoff. The handoff form will be utilized
in order to give report in a consistent ordering. Furthermore, nurses will fill out handoff sheets
before change of shift communication and give the report form to the oncoming nurse. Nurses
will also have the electronic medical record open during handoff report. After development of a
standardized handoff report form and implementation of bedside report, nursing staff will
participate in simulation exercises to practice proper handoff communication. Nursing staff
satisfaction with the perceived effectiveness of the new handoff report form and format. Errors
in-patient care and sentinel event rates will then be compared to previous rates in order to
determine if errors have been reduced.
Implementation Plan
Implementation of standardized handoff communication tool and format will take place
over one year. Beginning January 2015 observation of nurses’ handoff communication as well
as data collection. After 2 months of data collection a handoff communication checklist and
communication tool will be developed. Beginning May 2015 mandatory bedside report will be
strictly enforced. In June, nurses will begin reviewing new handoff documentation. After time
for nurses to review, simulation will begin at the August. Nurses will participate in an in-service
simulation in order to practice the shift handoff reports. Finally at the beginning of October, the
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new handoff communication format will take full effect and should be strictly enforced by
December. Over the next year errors in patient care should be analyzed in order to determine if
they were caused by the handoff communication. The effectiveness of the standardized format
will then be evaluated. A timeline of the stated plan is outlined in figure IV.
Jan
Feb
March
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Data
Collection
Checklist
Development
Mandatory Bedside Report
Review of
Handoff
Documents
In-service
Simulation
Implementation
and begin of
longitudinal
review
Figure IV.
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Evaluation
In examining the effectiveness of the new standardized handoff communication tool and
format nurses will initially be observed during an in service simulation. The simulation will work
both to allow nurses to practice the standardized handoff format as well as to allow for
observation. Following simulation and implementation of the new handoff format nurses will be
observed on the unit by a trained observer. Observations will be recorded and compared with
documentation taken during pre intervention observations. In examining the effectiveness of
handoff communication in preventing errors in patient care, it is necessary to examine the cause
of errors both before the implementation as well as after. The new handoff communication tool
and format will be shown to be effective if there is a decrease in errors in patient care, especially
sentinel events, following implementation. The difference in rates of adverse patient events will
be assessed for a minimum of one year following the final implementation phase. Finally a
survey of experienced nursing staff will be given in order to determine nurse perception of new
handoff communication format and decipher any necessary adjustments. The survey will seek to
determine nursing satisfaction as well as the nurses’ perception of the effectiveness of bedside
report in enhancing nurse/patient relationships.
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References
Berkenstadt, H., Haviv, Y., Tuval, A., Shemesh, Y., Megrill, A., Perry, A., & ... Ziv, A. (2008).
Improving Handoff Communications in Critical Care Utilizing Simulation-Based
Training Toward Process Improvement in Managing Patient Risk. Chest, 134(1), 158162. doi:10.1378/chest.08-0914
Evans, D., Grunawait, J., McClish, D., Wood, W., & Friese, C. R. (2012). Bedside Shift-to-Shift
Nursing Report: Implementation and Outcomes. MEDSURG Nursing, 21(5), 281-292.
Joint Commission on Accreditation of Healthcare, 2005 Joint Commission on Accreditation of
Healthcare. (2005). Improving America's Hospitals, A Report on Quality and Safety, (pp.
1--139). Retrieved from www.Jointcommissionreport.org
Klee, K., Latta, L., Davis-Kirsch, S., & Pecchia, M. (2012). Using Continuous Process
Improvement Methodology to Standardize Nursing Handoff Communication. Journal Of
Pediatric Nursing, 27(2), 168-173. doi:10.1016/j.pedn.2011.08.005
Radtke, K. (2013). Improving patient satisfaction with nursing communication using bedside
shift report. Clinical Nurse Specialist: The Journal For Advanced Nursing Practice,
27(1), 19-25. doi:10.1097/NUR.0b013e3182777011
World Health Organization, (2007). Communication During Patient Handovers. Retrieved from
http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf