Nursing Handoffs: A Systematic Review of Research Evidence

Introduction and Definition of Nursing Handoffs

It is extremely rare that a single patient is overseen by the same nurse throughout the duration of his or her care. Additionally, nurses must frequently communicate orders to patients and their families before the patient is released. Thus, nursing handoffs—or a shift in care-related responsibilities—are a critical component of daily nursing practice. The purpose of the systematic research review, "Nursing Handoffs: A Systematic Review of the Literature," was to determine what safe and effective practices regarding this aspect of nursing care are based upon the evidence provided by existing empirical studies.

Handoffs are not simply a change in personnel; they are critical junctures of care where information may be lost or important connections may be made, which result in substantive improvements in patient health. In fact, handoffs are considered important enough that the Joint Commission on Nursing has a specific definition in its literature for the process. Handoffs take place when "information about patient/client/resident care is communicated in a consistent manner" either between healthcare providers or between providers and patients for the purposes of continuity of care (Riesenberg, Leisch, & Cunningham, 2010). However, communication failures often result in health-related problems or medical errors during the handoff process, and thus more intensive research is needed to determine why this occurs and how to improve the process.

The Problem: Error Rates and Communication Failures

In the initial literature review on the subject by Riesenberg, Leisch, and Cunningham (2010), the authors cite evidence supporting the value of the subject matter. Nearly two-thirds of all handoffs are associated with adverse events of some kind. An Australian study of more than 14,000 handoffs found that "17% were associated with an adverse event; [and] in 11% of those events, communication problems were found to be a contributing factor" (Riesenberg, Leisch, & Cunningham, 2010). Another study of medical errors during handoffs found that miscommunication between physicians and nurses was a determining factor in 37% of errors (Riesenberg, Leisch, & Cunningham, 2010).

Non-standardized communication patterns were cited as the most frequent reason for this issue, such as the different perspective between physicians and nurses or errors regarding abbreviations in transmitting vital patient data. Given these high rates of errors, the purpose of the systematic research review was to determine both the level of quality of research-based information on the subject of handoffs as well as to provide information about best practices.

Methodology and Quality Assessment of Reviewed Studies

Over the course of the research review, ultimately twenty studies were selected from major online medical databases: MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, CINAHL, HealthSTAR, and Christiana Care Full Text Journals@Ovid. Of these selected relevant studies, "fifteen (75%) of the research studies involved an intervention, four (20%) were cross-sectional, and one (5%) was qualitative" (Riesenberg, Leisch, & Cunningham, 2010).

To determine quality of research, an objective, empirically-validated outside instrument was used entitled the Quality Scoring System. "Quality assessment scores for the 20 research studies ranged from 2 to 12 (possible range, 1 to 16). Many, though not all, of the studies concerned quality initiative projects. The majority of the research studies (17 of 20 studies; 85%) received quality scores at or below 8, with nine receiving scores between 2 and 5, and eight receiving scores between 6 and 8. Only three studies achieved quality scores above 10, with scores of 10.5, 11, and 12" (Riesenberg, Leisch, & Cunningham, 2010). Overall, this suggests a relatively low level of quality in the extant research on the subject. It should be noted that the instrument was not designed specifically to evaluate the studies by the authors and had been used to rate different research studies on a variety of subjects.

Key Findings: Interventions and Comparative Systems

After reviewing the quality ratings, the authors then briefly discussed some of the most pertinent studies. They noted that only half of the studies discovered interventions which appeared to be effective. Some of these interventions were highly specific to particular patient populations. For example, one of the studies of handoffs regarding child patients found that parental input was helpful when nurses engaged in rotations. Another study found that verbal patient participation in shift reports versus recorded shift reports enhanced patients' senses of well-being (although efficacy of care was not studied). Other studies found a reduced need for overtime for nurses and reduced stress levels for nurses and patients with "the implementation of walking rounds, bedside shift reports, or a customized telephone-based system," which in conjunction enhanced accuracy regarding patient information (Riesenberg, Leisch, & Cunningham, 2010).

The studies which involved the creation of new, formalized reporting systems designed to improve upon older ones usually compared some form of oral transmission of information with written transmission. One comparative study involved an analysis of taped versus face-to-face shift reports for "congruence, omissions, and omissions leading to incongruence" (Riesenberg, Leisch, & Cunningham, 2010). Taped reports were more laden with omissions but less likely to be incongruent. Another study involved a healthcare system in which all patient information was located in written form in a binder outside the patient's room. "Comparing the old system with the new one, the investigators demonstrated that the recording of medical histories improved from 55% to 100%, compliance with flow-sheet documentation increased from 45% to 100%, and the recording of intravenous catheter insertion dates improved from 75% to 95%" (Riesenberg, Leisch, & Cunningham, 2010). Several other studies substituted written data for telephoned and oral reports, resulting in improved transmission of data.

Critical Analysis and Methodological Limitations

While some of the findings from the different studies were interesting, they were presented in extremely piecemeal fashion by the researchers with few headings or breaks in the narrative of the review. There was no clear delineation between the different types of research studies; even the qualitative versus quantitative categories were not distinguished in terms of the presented evidence. While the quality scores of the different studies were reported independently, only the results of the different studies were presented in narrative form, without a discussion of the quality of evidence of the findings, as determined by the researchers. This made it extremely difficult to evaluate the quality of evidence in terms of generating recommendations for policy improvements and changes.

The rationale behind the quality scoring was also not clear. Although the instrument had been used previously, other than the fact that the rating levels spanned from 1 to 16, there was no discussion of why the different gradients were useful in their application to this particular study. Overall, the general consensus which emerged from the reports was that putting the data regarding patient orders into writing did result in improvements, although this was not a consistent theme explored across all research studies.

Unresolved Questions and Practical Concerns

For example, one study found that oral interviews enhanced patient well-being, but this was not necessarily synonymous with efficacy. "Although patient satisfaction and decreased overtime are important outcomes, it's not clear to what degree those are features of more effective handoffs" (Riesenberg, Leisch, & Cunningham, 2010). The use of a formal, problem-oriented form was found to save nurses time but not necessarily an enhancement to accuracy. In one research comparison, taped reports were more likely to produce omissions versus face-to-face interactions, the latter of which showed greater congruency, but these findings were not compared with written data in that study.

Overall, despite the researchers' contention that there was a unified purpose to the review, there was a great deal of inconsistency in the aims of the reports. Enhancing patient well-being or improving speed of care delivery is not synonymous with actual quality and accuracy, but reports which focused on these measures were included as well as those which focused upon error reduction and quality improvement. While the stress upon writing down reports in roughly half of the studies was valuable, this still consisted of a relatively narrow base of support (approximately ten studies).

The conclusions of the study were thus based upon a relatively narrow range of data sets, and the idea that written reports are superior to oral reports must be viewed with caution. The loss of patient-nurse contact must also be evaluated to see if the sacrifice of a personal connection is warranted. There is also the question of additional layers of bureaucracy to keep track of the additional paperwork involved in written reports. Confidentiality and security of written data is also a concern, and the question of whether such medical records should be digitized is left unanswered. One study encouraged the use of patient data left in a binder by the patient's bedside which could presumably be read by anyone strolling by. The practical reasons for previously using oral transmission of patient data during transfers of care (such as confidentiality and clarifying orders) were not listed or rebutted.

Conclusion: Evidence Gaps and Future Research Needs

Finally, although not the specific focus of the studies, the reasons for miscommunication and errors were not fully addressed: "lapses in communication or failures to communicate, lengthy or irrelevant content, and inaccurate recall of communicated information...language barriers, illegible handwriting, and poor communication between nurses and physicians" (Riesenberg, Leisch, & Cunningham, 2010). Many of these problems can still occur in written communication, and a few might even be exacerbated with written orders such as illegible handwriting and the different terminology used by nurses and physicians (Riesenberg, Leisch, & Cunningham, 2010). While this research review is a useful beginning for a discussion of the issue, many questions remain unanswered, and more rigorous, consistent research is needed to establish evidence-based best practices for nursing handoffs.