Exploring the State of the Science of the Nursing Hand-Off Communication
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CONTINUING EDUCATION ANCC 1.5 CONTACT HOURS Exploring the State of the Science of the Nursing Hand-off Communication Benjamin J. Galatzan, MSN, RN, Jane M. Carrington, PhD, RN, FAAN repeated testing.2,3 The negative consequences of these errors Miscommunication that occurs during the exchange of infor- mation between healthcare providers accounts for approxi- for the patient are extended hospitalization, increased costs, 2,4 mately 80% of adverse events in the healthcare setting. and actual harm. The Joint Commission considers the im- Nurses devote 10% to 15% of the workday to the nurse-to- provement of healthcare provider communications and timely nurse hand-off communication. The hand-off itself has re- communication of patient information as National Patient mained virtually unchanged for the past 20 years, although Safety Goals.5 The transition of patient care has several dif- the process is prone to errors. The introduction of the elec- ferent labels: hand-off, handover, patient rounding, and change- tronic health record and mandates to decrease errors and of-shift report. The transition of care for the purpose of this improve patient outcomes has led to an influx of research article will focus on the nurse-to-nurse hand-off communication. on the nurse-to-nurse hand-off communication. This article The nurse-to-nurse hand-off communication is defined provides a comprehensive synopsis of the hand-off and the as the transfer of patient care and responsibility from one state of science on nurse-to-nurse communication using healthcare provider (eg, nurse, physician, or nurse practi- hand-offs. In general, the use and implementation of stan- 6–8 dardized tools and the nurse's perception of and satisfac- tioner) to another. The Joint Commission in 2006 issued tion with the hand-off communication have been researched a mandate calling for the development and implementation 9,10 extensively. A standardized hand-off tool increases nurse satis- of a standardized hand-off template. In 2012, The Joint faction with the structure and consistency of the hand-off. Commission released a suite of tools to assist with implemen- While electronic health record–related forms and devices are tation.1 Currently, several templates have been implemented not utilized by nurses, communication patterns and communi- in various inpatient and outpatient settings with the intent – cation behaviors can also influence the effectiveness of the to improve hand-off communication.2,11 23 Unfortunately, hand-off message. The areas of memory, cognition, and con- little is known as to patient outcomes as a result of the imple- tent of the hand-off affect the transfer and recall of hand-off in- mentation and usage of standardized templates. We present formation. Continued research on hand-off communication is the results of a comprehensive state of the science of nurse- essential to ensure patient safety. to-nurse communication using hand-offs. KEY WORDS: Communication, Handoff, Handover, Nursing, Standardized tool, Systematic review BACKGROUND Transferring the responsibility of patient care from one nurse to another can occur multiple times per day. Addi- tionally, 10% to 15% of the workday is devoted to nurse-to- pproximately 80% of errors in healthcare are 24 credited to miscommunications occurring during nurse communication. The hand-off occurs at the change the transfer of care.1 Thepossibleerrorsthat of shift, between nursing units (intradepartmental), interde- occur as a result of miscommunication during partmental (test, procedures, and therapies), and when the pa- thetransferofcarearedelayeddiagnosis,delayed tient transfers from one healthcare facility to another. The A nurse-to-nurse hand-off involves communicating patient data, or omitted treatments including medications, and missed or information, and knowledge to ensure patient safety and con- 21,25,26 Author Affiliations: Helen & Arthur E. Johnson Beth El College of Nursing and Health Sciences, tinuity of care. The hand-off communication requires University of Colorado, Colorado Springs (Mr Galatzan); and University of Arizona, College of Nursing, Tucson (Mr Galatzan and Dr Carrington). an extensive amount of cognitive awareness and functioning 8 The authors have disclosed that they have no significant relationships with, or financial interest while nurses analyze and synthesize the information. The in, any commercial companies pertaining to this article. hand-off traditionally occurs in one of the following methods: Corresponding author: Benjamin J. Galatzan, MSN, RN, Helen & Arthur E. Johnson Beth El College taped, verbal at the bedside, or verbal not at the bed- of Nursing and Health Sciences, University of Colorado Colorado Springs, University Hall, 1420 4,12,20,27 Austin Bluffs Pkwy, Colorado Springs, CO 80918 ([email protected]). side. The hand-off also serves other functions such Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. as socialization, team building, emotional support, and educa- 28,29 DOI: 10.1097/CIN.0000000000000461 tion (teaching and learning). The nurse-to-nurse hand-off 484 CIN: Computers, Informatics, Nursing October 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. communication is not formally taught in nursing education articles in English, both quantitative and qualitative in na- but is acquired through observation and on-the-job training. ture, that were published within the identified 10-year The format of the nursing hand-off has changed little over span from 2007 to 2017. Additional inclusion criteria the past 20 years despite evidence of the process being suscep- were a primary focus on nurse-to-nurse communication, tible to miscommunication. cognition, and memory. Exclusion criteria were book Most adverse events affecting patient outcomes are the reviews, non-English articles, letters to editors, books, com- result of miscommunication rather than provider compe- mentaries, literature reviews, and abstracts for presentations. tency or skill.30 Two of the most influential healthcare orga- The initial search and the supplemental search resulted in nizations, The Joint Commission10 andtheWorldHealth 260 articles. The results were reviewed, and duplicates were Organization,30 have mandated the implementation of a eliminated. The remaining article abstracts were evaluated standardized hand-off. These initiatives have led to the for retention based on relevance to the subject and the in- development and implementation of several standardized clusion and exclusion criteria. A total of 30 articles were hand-off tools and checklists,29 including Situation Back- retained for evaluation. A comprehensive summary of the ground Assessment Recommendation (SBAR), Illness se- articles included in the systematic review is shown in Table 1. verity Patient summary Action list Situation awareness and contingency planning Synthesis by receiver (I-PASS),9,23 In- RESULTS troduction Situation Background Assessment Recommen- The systematic review was analyzed using thematic anal- dation (ISBAR); Name Unexpected outcomes Tubes Safety ysis methodology to identifythemesorcategoriesinthe 18 scan (NUTS); Record Evidence Enquire Discuss (REED); textual data.45 The following six themes were identified in Presenting information Vital signs Input/output Treatment the nurse-to-nurse hand-off communication systematic review Admission or discharge criteria and Legal documents of the research: standardized tools, nurses' perception of and (P-VITAL); and Identification of the patient Clinical history/ satisfaction with the hand-off, communication and commu- presentation Clinical status Care plan Outcomes and goals nication patterns, use of electronic tools, hand- off content, 31,32 of care (ICCCO). As demonstrated by this list, no single and cognition/memory. A majority of the articles (21 of method or approach has been recommended for widespread the 30) focused on standardized hand-off tools and the implementation. The nursing community has not been able nurses' perception of and satisfaction with the hand-off. to agree as to the structure or clinical content for a standard- ized hand-off.29,33 Standardized Hand-off Tools Nurse-to-nurse hand-off communication has been researched A standardized hand-off tool, as defined by the literature, is a extensively and emphasized in the literature as an area of predetermined form that provides a structured sequence of importance because of its role in patient safety. The stan- information for the hand-off communication.6,13,15,16 The dardized templates provide a structure for the hand-off but structured sequencing of information also provides consis- do not address content. Even with the increased emphasis tency to the hand-off process. There are numerous struc- on the hand-off communication, many questions are left un- tured models of hand-off tools that have undergone research, answered. What is the current state of the science of nursing including REED, ISBAR, SBAR, and ICCCO.17,20,24,32 The hand-offs? What does the research indicate as best practice? advantages of implementing a standardized hand-off tool are Where should nursing scientists focus future research on decreased information overload, increased quality of the infor- nurse-to-nurse hand-off communication? mation exchanged,32 decreased risks to patient safety, and improved patient outcomes.16 Several factors must be con- METHODS sidered before implementing a standardized hand-off tool A comprehensive literature review was conducted to identify for