A systematic review of nursing inter-shift reports in adult acute care settings

Background Continuity of patient care has been identified as a key component of patient safety. 1 The handoff, also called a handover, is the transfer of patient care responsibilities from one healthcare practitioner to another, and is a universal procedure used in hospitals used to promote continuity of care. The most widespread of these handoffs are the inter-shift nursing reports, which occur multiple times a day. The Joint Commission (TJC), a US based accrediting agency for quality care, has acknowledged the importance of handoffs by adding it to their 2006 National Patient Safety Goals requiring that handoffs of patients between caregivers be standardized, with particular attention to providing the opportunity for asking and responding to questions. 2 Lack of attention to the process of handoffs, has been reported by TJC to result in a breakdown in communication, and implicated in two-thirds of all sentinel events reported with an overall result of discontinuity in patient care.2 Handoffs between caregivers are a frequent occurrence in the acute care setting. They happen formally at change of shift as well as informally many times each day as patients move from one level of care to another, as staff members transfer care to others, and as team members convey information regarding diagnostic tests and vital signs. The primary overt objective of the handoff is to communicate information regarding a patient's condition, treatment, and anticipated needs that are vital to care. A handoff is a complex process that involves the reassignment of a patient from one practitioner to another. Critical thinking, and therefore patient safety, is enhanced when there is valuable and mutually respectful communication during the handoff. 3 The primary objective of the handoff is the accurate transfer of information about a patient's state and care plan. 4 However, there is speculation that handoffs fulfill a wide range of functions other than the transfer of patient care information. 5-6 It has been noted that the most common of these handoffs, the change of shift report, not only serves to facilitate continuity of care for the patient, but also offers nurses a comforting ritual, 7 which helps solidify team cohesion 8. A study of nurses caring for dying patients found, for example, that face-to -ace handoffs serve a supportive and comforting function. 9 Whether ritual, team building tool or goal directed practice, the handoff process provides an opportunity for communication between caregivers. Handoffs can also be problematic, however, having been described as being fraught with risks and hazards that have the potential to result in active or passive failure. 10 Consequently, hospitals are engaged in a frenzy of activity to meet the mandate for a standardized approach to “handoff” communications, that includes an opportunity to ask and respond to questions, and that also serves to improve communication between and among caregivers and decrease error. There is some evidence to support that ineffective handoffs can lead to wrong treatment, delays in diagnosis, severe adverse events, patient complaints, increased cost and longer lengths of stay. 11-12 In Canada, for example, a study in Emergency Departments found that information handed off varied considerably, interruptions were frequent, and the location of the handoff changed repeatedly. 13 Patterson and colleagues 8 have identified some of the potential costs of failing to be told, forgetting, or misunderstanding information communicated during a shift change handoff. These include: being unaware of significant data or events, being unprepared to deal with the impact of previous events, failure to anticipate future events, and lack of knowledge to perform necessary tasks. While this research was conducted with space mission controllers, the impact on nursing units is enormous. Consider, for example, the case of Willie King in Tampa, Florida, who had the wrong leg amputated because one nurse did not relate to the next nurse that the wrong leg for amputation had been entered into the computer, and although the error had been corrected, an old report was used during the handoff. 14 As new processes related to nursing handoffs are put into place in hospitals, it seems appropriate to ask: “What have researchers found about the process of inter-shift reports between and among nurses in acute care settings?” To answer this overarching question, a systematic review is proposed. It is a long held assumption that oral communication of patient status during handoffs is a critical link in the chain of continuity of care and essential to provision of safe care. If this is so, then number of handoffs would be irrelevant as each would fulfill the requirement of passing on information necessary for seamless transition to the next caregiver. However, a study of low risk pregnant women found a correlation between number of staff handoffs and incidence of unplanned Cesarean Section. 15 Another study found faulty information transfer at shift change to be a factor contributing to decreased patient familiarity leading to harm in surgical patients. 16 An initial review of the literature found a case study describing the fatal consequence of non-communication of a critical radiological scan result. 17 These findings and others lead one to ask whether the traditional unstructured handoff report can be relied upon to support safe patient care in these times of complex multidisciplinary care. Further, it has been pointed out that the complexity of the patient and work environment make it difficult for people to recall and transfer information in an informal way 18 and there is often incongruence between the description of patient condition during report and actual condition found after the report.19 Caregivers often think about barriers to communication in terms of those which exist between patients and caregivers, however misinterpreted or missing communication between caregivers during handoffs are more insidious and can lead to dire lapses in care. Clearly, it is necessary for each caregiver to have a thorough knowledge of patient condition and care needs, but perhaps it is time to question whether the traditional oral change of shift report is the ideal mechanism for this knowledge transfer, and to identify standards for nursing knowledge transfer at transition points in the acute care setting. Certainly nursing's mantra that “if it's not documented, it's not done” suggests an emphasis on complete and accurate documentation, so why is so much time and emphasis placed on the oral handoff when the formal medical record contains everything there is to know about the patient? To answer these questions, an understanding of the current process of inter-shift nursing handoffs needs be formulated. As McLuhan 21 has argued there are multiple subtle effects that engage participants in different ways during an interaction, and that the use of multiple means of communication is associated with differing degrees of involvement and understanding. This argues in favor of utilizing multiple forms of communication. The result of this review will be significant as handoffs tend to be time consuming, and therefore, costly, and take nurses away from the bedside. It is important to develop an understanding of best practice in communication related to knowledge transfer during transitions in care in order to utilize this precious time optimally. Review question/objective The aim of this systematic review is to describe the process of inter-shift nursing handoff procedures and to identify commonly used strategies and techniques associated with the handoff. Specifically, in relation to inter-shift nursing handoffs in acute care settings: How were they conducted? Where were they conducted? How was information transferred? What purpose(s) did the handoff serve? Can best practice related to knowledge transfer during transitions in care be identified? Inclusion criteria Types of participants The review will consider studies that include nurses engaged in handoff activities in adult acute care settings at the time of inter-shift nursing report. Types of studies This review will consider qualitative studies and will include those that focus on: phenomenology, grounded theory, narrative analysis, action research, ethnographic or cultural studies. In the absence of research studies, other texts such as opinion papers, commentaries and reports will be considered in a narrative summary. Types of intervention(s)/phenomena of interest This component of the review will consider the following phenomena of interest: The processes associated with inte-rshift report on acute care nursing units, specifically, where they were conducted, how information was transferred between or among participants, and what information was transferred between or among participants. Types of outcomes Outcomes of interest are connected to the process of inter-shift nursing handoffs in acute care settings. Outcomes are related to the various purposes the handoff may serve, in addition to the transfer of patient care information, and the identification of best practice related to knowledge transfer during transition in care. Search strategy A comprehensive electronic search of full text English language articles indexed in using the key words: communication; therapeutic communication; transitional care; transitions; inter-shift report(s); shift report; nursing shift report; handoff(s); handoff report; handoff communication; communication breakdown; communication lapse(s); information transfer, handover, handover communication, handover report is proposed. Alternative spellings and usage such as hand off, hand over, handover and intershift will also be considered. The search strategy aims to find both published and unpublished studies between the years 1988 and 2008 as that is when significant changes in handoff procedures occurred. A three-step search strategy will be utilized in each component of this review. Firstly, an initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords, and expanding the list as appropriate after the initial search, and index terms will then be undertaken. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies. The other databases to be searched will include: PubMed MEDLINE HealthStar ScienceDirect Dissertation Abstracts International/Digital Dissertations DARE PsycINFO BioMedCentral TRIP (Turning Research into Practice) Pre-CINAHL - for research still being indexed in CINAHL PsycARTICLES Psychology and Behavioural Sciences Collection ISI Current Contents, Science.gov Theses Canada Web of Science/Web of Knowledge Scirus.com website Although there are no journals specific to the topic of nursing handoffs or clinical communication, journals devoted to acute care nursing issues, such as Journal of Advanced Nursing and The Journal of Critical Care will be hand-searched in order to be as complete as possible in finding studies regarding the nursing handoff. Also, when searching for opinion-based data, the keywords terms will be used in conjunction with such terms as: comment(s), commentary/commentaries, editorials, editorial opinion(s), expert opinion(s), reply/replies/rejoinder(s). The search for unpublished studies or grey literature will include a search of GoogleScholar/Advanced and studies' footnotes. A more extensive search for grey literature will be undertaken if there is a lack of consensus present or the availability of research-based evidence is of low volume or quality. The potential grey literature sites will include: ‘Grey Literature Report' from New York Academy of Medicine National Library of Medicine and NIH subset and NLM Gateway Proceedings First Institute for Health & Social Care Research (IHSCR), http://www.ihscr.salford.ac.uk/researchreports AHRQ (Agency for Healthcare Research and Quality) CEEHD (Centre for Evidence in Ethnicity, Health and Diversity Clinical Medicine Netprints Collection Geneva Foundation for Medication Education and Research (GFMER) Grey Source: A Selection of Web-Based Resources in Grey Literature HMIC (Health Management Information Consortium) NurseScribe Index to Theses The Qualitative Report (http://www.nova.edu/ssss/QR/aindex.html) WHOLIS: WHO Organization Library database Assessment of methodological quality Research papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the JBI-QARI (Appendix I) and JBI-NOTARI (Appendix II) Any disagreements that arise between the reviewers will be resolved through discussion with a third reviewer. Search strategy will begin with reviews of abstracts of studies identified for relatedness to the topic of interests by the two independent reviewers. Once abstracts are assessed for relevance, the full text will be obtained for another review. The two reviewers will share with each other their researched full texts and discuss which among the researched full text are highly suggestive of the topic. Data collection Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix III) and JBI-NOTARI (Appendix IV). Data synthesis Where meta-synthesis is possible, qualitative research findings will be pooled using the JBIQARI and JBI-NOTARI programs. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings), rating them according to their quality, and categorizing these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a metasynthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings), which can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. The process of meta-synthesis embodied in these programs involves the aggregation or synthesis of findings/conclusions made in relation to the phenomenon under review. The aim of the process is to generate a set of statements that represent aggregation through assembling the findings or conclusions rated according to their credibility, and categorizing these findings/conclusions on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that are used as a basis for evidence-based practice. The features of content analysis incorporated into these programs include the need to read and reread the text to identify the meaning of the content, and the formation of statements that accurately describe the content. The features of discourse analysis that these programs draw on are the steps pursued to identify the degree to which the text being reviewed has ‘authority' in so far as its purpose and its focus on serving the best interests of health care recipients. Expert opinion as expressed by an individual, a learned body or by a group of experts via a consensus guideline will be included in this review as the opinions of experts is central to identifying best available evidence for practice. Conflicts of interest None

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