Dr. Adams is Nurse Scientist, The Yvonne L. Munn Center for Nursing Research and The Center for Innovations in Patient Care, Massachusetts General Hospital, Boston, Massachusetts. Ms. Osborne-McKenzie is Critical Care Director, Critical Care, Salinas Valley Memorial Healthcare System, Salinas, California.
This research was supported in part by a Sigma Theta Tau Rho Chapter Research Grant and a Yvonne L. Munn Postdoctoral Fellowship Grant.
The authors thank Lynda Brandt, Susan Lee, Irene Ramirez Neumeister, Marion Rideout, and the Salinas Valley Memorial Healthcare System Handover Team for their contributions to the development of this manuscript.
Address correspondence to Jeffrey M. Adams, PhD, RN, The Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, 275 Cambridge Street, Boston, MA 02114. E-mail: firstname.lastname@example.org.
Handover communications during nursing shift changes provide accurate, up-to-the-minute information about a patient’s care, treatment, services, current condition, and recent or anticipated changes. The number of health care providers involved in the care of each hospitalized patient makes communication an essential component of patient safety. However, handover can be particularly vulnerable to communication failures (Riesenberg, Leitzsch, & Cunningham, 2010). Handover communications take place more frequently than just at shift change. For example, throughout a patient’s stay in the hospital, critical communication exchanges occur when temporary relief coverage is required. In addition, staff nurses update physicians, the patient, and the patient’s family throughout the hospital stay and at discharge. Because of the frequency of these exchanges and the multitude of handover approaches, critical patient information may be omitted, may not be fully explained, or may be obscured by irrelevant information (Caruso, 2007).
Although much work has been done to develop a standardized process for handover, health care providers continue to struggle with the best way to communicate necessary information effectively and efficiently during transitions (Riesenberg et al., 2010). Medical errors most commonly occur after breakdowns in handover communications (Institute of Medicine, 2005). A recent analysis of evaluation notes conducted by The Joint Commission indicated that communication failures caused nearly 70% of sentinel events, with at least 50% of those occurring during handover (Joint Commission Resources, 2006). Standardizing the informational elements of handover can improve communication by decreasing the amount of information that health care providers leave to chance. The Joint Commission defined standardized handover as a process in which information about patient, client, or resident care is communicated in a consistent manner from one care provider to another (Joint Commission Resources, 2006). This article focuses on the structure of handover, but it is important to note that there are many components to understanding and maximizing the overall handover process. The five components of hand-over—structure, knowledge, interaction, language, and settings (SKILS)—and supporting literature are shown in the Table.
Table: Skils—Handover Components
Standardizing each of these components of hand-over not only minimizes variability in communications but also develops a certainty around the transfer of vital information from one provider to another. “Concise reporting that minimizes duplication yet avoids missing information is a complex job; tools that simplify and standardize the process help,” according to Wilson (2007, p. 204). In response to the identified potential for errors occurring during patient handover, The Joint Commission established a National Patient Safety Goal requiring hospitals to implement a standardized approach to handover communications that is used throughout the organization (Joint Commission Resources, 2006). The importance of a tool to facilitate nurses’ focus during each handover experience, inclusive of time to ask questions, has been well documented in the literature (Sidlow & Katz-Sidlow, 2006).
The prevailing gold standard handover structure is Situation-Background-Assessment-Recommendation (better known as “SBAR”). SBAR was originally developed and effectively used during submarine duty handover by the U.S. Navy. It was later adapted to provide structure for the physician-to-physician handover process (Leonard, Graham, & Bonacum, 2004). However, SBAR may not be the best framework to articulate, capture, or support the information that nurses need to share when conveying their knowledge about a patient. In many settings, nurses are accountable for individual and family care 24 hours a day, 7 days a week, with increasingly complex patient conditions, needs, and rarely a status quo. Accurate communication with other providers about nursing diagnoses, interventions, and responses, coupled with logistical patient care needs, such as upcoming tests, treatment results, and planned procedures, is essential. Because of the narrative culture of nursing, the unique knowledge that nurses must share, and the total number of handovers that nurses initiate and receive, an effective standardized handover format is challenging to identify (Patterson & Wears, 2010).
Impetus for the Study
When the nursing staff at one Central Coast California District Hospital initiated the use of the SBAR structure, a nursing director observed inconsistencies in the transfer of knowledge during shift-to-shift handover communications. For example, pertinent information was not communicated, orders were not clarified, and in many cases insufficient time was available to accommodate on-coming staff’s need for additional information. It was perceived that these deficiencies in handover communications stemmed from an inability to accommodate the fluidity that naturally occurs in the dynamic hand-over conversation. In practice, nurses could not communicate accurately or clarify information conversationally with the SBAR structure, and in this way, the SBAR format underperformed during a critical element of patient care, the handover transition.
Two theoretical perspectives provide the underpinnings for this study. The Adams Influence Model (AIM)© emphasizes the factors, attributes, and process of influence and emphasizes the importance of the dynamic relationship between the provider and the receiver of information in achieving desired outcomes (Adams, 2009) and in matters requiring clear communication (Adams & Ives Erickson, 2011). The O’Rourke Professional Role-Based Model (PRBM)© emphasizes each nurse’s role in creating an effective handover communication from knowledge dispensed from the leader, scientist, practitioner, or transferor of information (Cornett & O’Rourke, 2009; O’Rourke, 2003). Together, the AIM© and PRBM© provide clarity and a theoretical grounding in the importance of professional nursing communication.
This study consisted of a two-step evaluation process using a secondary qualitative (Turner, 1997) directed content analysis (Hseih & Shannon, 2005) of performance improvement interview data. Content analysis as a research method quantifies qualitative data and provides a mechanism for developing and analyzing this synopsis. Content analysis using a directed approach includes a more structured process than traditional content analysis (Hickey & Kipping, 1996). Directed content analysis generally starts with a theory or relevant research findings and uses pre-existing concepts from the particular theory or research findings to code or structure the results (Hseih & Shannon, 2005). Subsequently derived themes can then be used to further validate or extend a conceptual framework or theory (Zhang & Wildemuth, 2009). Content analysis and more specifically directed content analysis provide a unique mechanism for the quantified evaluation of persons, models, and existing practice frameworks through coding and structuring of the various forms of qualitative data.
Source data were collected as part of staff performance improvement project interviews. The Salinas Valley Memorial Healthcare System institutional review board granted exempt status to this study (institutional review board study #00004285). The original convenience sample was selected across five nursing units (three medical-surgical, one pediatric, and one mother-baby) in a Central Coast California District Hospital. Eligible participants were registered nurses who were regularly assigned to the units and available for interview. Subjects were asked to complete a short demographic form and verbally answer the following question: “What is necessary to hear in shift report in order to deliver competent care?”
Verbal responses to the query were digitally recorded and transcribed. Data were analyzed with directed content analysis by a team of three researchers, including two doctorally prepared nurse researchers and a master’s-prepared nurse subject matter expert. SBAR, the structure recommended by the World Health Organization (WHO-SBAR), was used in conjunction with The Joint Commission Communication During Patient Handover (TJC-CDPH) for directed content analysis categories, shown in the Figure, rows B and C, respectively. Using these methods, the researchers isolated the concepts (N = 146) identified in the text of staff nurses’ perceptions of information that was necessary to deliver competent care that represented the concepts described in the WHO-SBAR and TJC-CDPH. Interrater reliability was established through cross-comparison of each concept’s categorization by each of the three researchers. If one researcher “disagreed,” then that item received a score of 0%. If all three researchers’ categorizations matched, then the item was scored as 100%.
Figure. D-BANQ mapped: handover structure tool. Dx = diagnosis; Tx = treatment; Pt = patient.
Minimal demographic information was collected as part of the source performance improvement project. On average, nurse participants (N = 20) had worked as registered nurses for 9.5 years, with 5.9 years at the study site hospital. In all, 60% of nurses in the study held an associate’s degree in nursing, and the rest had a baccalaureate degree. On initial review, researchers yielded low (45%) interrater item reliability when they individually categorized content into the WHO-SBAR and TJC-CDPH formats and then cross-compared the categorizations. For example, laboratory results were identified as fitting into the situation, background, and assessment categories by each of the researchers.
The research team noted their difficulty in agreeing on which of the WHO-SBAR and TJC-CDPH categories related to the context of each response. Continued immersion in the data and researcher discussion yielded the emergence of new themes that further clarified the definitions of the SBAR and CDPH format categories: Demographics and Stability, Before I Began to Provide Care, As I Provided Care, and Next Care Provider Needs to Know (D-BAN). The same research team then independently categorized the 146 concepts “necessary to deliver competent care” using this new D-BAN categorization. They achieved 100% interrater reliability with this new structure. Additional content validity of the new D-BAN handover format was then explored with a convenience sample of seven staff nurses. During this construct validation, the chronological D-BAN approach also benefited from an opportunity to ask questions and receive clarification, adding the final theme to the new structure, Q, making the format D-BANQ. D-BANQ, as represented in the Figure, row A, aligns with the prevailing WHO-SBAR and TJC-CDPH frameworks in rows B and C, respectively.
The emergence of D-BANQ as a model structure for a standardized provider handover format warrants additional exploration. This study is supportive of both the WHO-SBAR and the TJC-CDPH structures and also provides clarity for a chronological approach. The WHO-SBAR and TJC-CDPH provide a positive basis for improving communication, and the D-BANQ format advances this strategy. Because this is a preliminary study with a small sample size, the ability to generalize across provider populations is limited. D-BANQ is not meant as a replacement for the existing standard structure of WHO-SBAR or TJC-CDPH. Rather, D-BANQ best serves as an overlay, clarifying the structure to best capture nurses’ practice when delivering care. D-BANQ provides additional clarification to the handover structure that will prove especially useful for nurses in all care transitions, whether completing shift report in the acute care setting, transferring care to a rehabilitation facility, or sharing information with a colleague for home care. Initial discussions led by the authors with acute care staff nurses suggested that D-BANQ functioned as a useful mechanism for improving handover communications because it supports the complexities of professional nursing practice.
Effective communication between nurses and other care providers is an essential component of the nurse’s role in continually influencing and improving patient outcomes. D-BANQ comports to current WHO-SBAR and TJC-CDPH standards while providing additional refinement and clarification to assist in preventing errors and maximizing patient transitions. Additional study is needed to explore the use of the D-BANQ handover structure, both within nursing and across other provider populations, to assess for the effect of each SKILS component across the continuum of health care and within non-health care high-reliability organizational domains. Thus, D-BANQ has far-reaching implications. In the future, D-BANQ can be explored as part of continued education, policy, practice, research, and theory development.
- Adams, J. M. (2009). The Adams Influence Model (AIM): Understanding the factors, attributes and process of achieving influence. Saarbrüken, Germany: VDM Verlag.
- Adams, J. M. & Ives Erickson, J. (2011). Applying the Adams influence model in nurse executive practice. Journal of Nursing Administration, 41(4), 186–192. doi:10.1097/NNA.0b013e3182118736 [CrossRef]
- Caruso, E. M. (2007). The evolution of nurse-to-nurse bedside report on a medical-surgical cardiology unit. Medsurg Nursing, 16(1), 17–23.
- Cornett, P. A. & O’Rourke, M. W. (2009). Building organizational capacity for a healthy work environment through role-based professional practice. Critical Care Nursing Quarterly, 32(3), 208–220.
- Currie, J. (2002). Improving the efficiency of patient handover. Emergency Nurse, 10(3), 24–27.
- Hess, D. R., Tokarczyk, A., O’Malley, M., Gavaghan, S., Sullivan, J. & Schmidt, U. (2010). The value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure. Chest, 138(6), 1475–1479. doi:10.1378/chest.09-2140 [CrossRef]
- Hickey, G. & Kipping, E. (1996). A multi-stage approach to the coding of data from open-ended questions. Nurse Researcher, 4, 81–91.
- Hseih, F. U. & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. doi:10.1177/1049732305276687 [CrossRef]
- Institute of Medicine. (2005). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
- Joint Commission Resources. (2006). Improving handoff communications: Meeting National Patient Safety Goal 2E. Patient Safety, 6(8), 9–15.
- Keenan, G. (1999). Use of standardized nursing language will make nursing visible. Michigan Nurse, 72(2), 12–13.
- Kitch, B. T., Cooper, J. B., Zapol, W. M., Marder, J. E., Karson, A. & Hutter, M. et al. (2008). Handoffs causing patient harm: A survey of medical and surgical house staff. Joint Commission Journal on Quality and Patient Safety, 34, 563–570.
- Lamond, D. (2000). The information content of the nurse change of shift report: A comparative study. Journal of Advanced Nursing, 31(4), 794–804. doi:10.1046/j.1365-2648.2000.01349.x [CrossRef]
- Leonard, M., Graham, S. & Bonacum, D. (2004). The human factor: The critical importance of effective teamwork and communication in providing patient care. Quality and Safety in Health Care, 13(Suppl. 1), i85–i90. doi:10.1136/qshc.2004.010033 [CrossRef]
- Meissner, A., Hasselhorn, H. M., Estryn-Behar, M., Nézet, O., Pokorski, J. & Gould, D. (2007). Nurses’ perception of shift handovers in Europe: Results from the European Nurses’ Early Exit Study. Journal of Advanced Nursing, 57(5), 535–542. doi:10.1111/j.1365-2648.2006.04144.x [CrossRef]
- O’Rourke, M. W. (2003). Rebuilding a professional practice model: The return of role-based practice accountability. Nursing Administration Quarterly, 27(2), 95–105.
- Patterson, E. S. & Wears, R. L. (2010). Patient handoffs: Standardized and reliable measurement tools remain elusive. Joint Commission Journal on Quality and Patient Safety, 36(2), 52–61.
- Riesenberg, L. A., Leitzsch, J. & Cunningham, J. M. (2010). Nursing handoffs: A systematic review of the literature. American Journal of Nursing, 110, 24–34. doi:10.1097/01.NAJ.0000370154.79857.09 [CrossRef]
- Sidlow, R. & Katz-Sidlow, R. (2006). Using a computerized sign-out system to improve physician-nurse communication. Joint Commission Journal on Quality and Patient Safety, 32(1), 32–36.
- Thede, L. & Schwiran, P. (2011). Informatics: The standardized nursing terminologies: A national survey of nurses’ experiences and attitudes. Online Journal of Issues in Nursing, 16(2), 12.
- Turner, P. D. ( 1997, March. ). Secondary analysis of qualitative data. Paper presented at the Annual American Educational Research Association Conference. , Chicago, IL. .
- Wilson, M. J. (2007). A template for safe and concise handovers. Medsurg Nursing, 16(3), 201–206.
- Woods, M. S. (2010). Effective handover communication, part 1: Developing and implementing new SBAR tool. Joint Commission Perspectives on Patient Safety, 10(1), 3–5, 11.
- Zhang, Y. & Wildemuth, B. (2009). Qualitative analysis of content. In Wildemuth, B. (Ed.), Applications of social research methods to questions in information and library science (pp. 222–231). Westport, CT: Libraries Unlimited.
|Handover Component||Description||Summary of Supporting Literature Reviewed|
|Structure||Broad categorization||SBAR (Situation-Background-Assessment-Recommendation) is the prevailing standard for handover in high-reliability settings (Woods, 2010).|
|Knowledge||What content is to be shared||Every patient handover needs to include information such as name and age, reason for admission, relevant medical history, treatment received, and plan of care (Currie, 2002).|
|Interaction||Verbal, written, or hybrid||Verbal exchanges are more likely to contain judgments about a patient’s condition and are more comprehensive about detail, even though patient notes feature more facts (Lamond, 2000). Additionally, hospital care cost was significantly lower when a verbal report was used, and supplementing a written report with a verbal discussion was associated with a significant reduction in cost (Hess et al., 2010).|
|Language||Shared meaning of concepts and words used||Nurses used individual or unit-specific terminology in documentation, limiting the opportunity for analysis, reporting, decision making, and articulation of disciplinary contributions (Keenan, 1999; Thede & Schwiran, 2011).|
|Setting||Physical surroundings that limit interruption||Clinician dissatisfaction with shift-to-shift handovers centers on two common occurrences: frequent disturbances and lack of time for questions (Kitch et al., 2008; Meissner et al., 2007; Wilson, 2007).|