Keys to an Effective Shift Report

1. Keys to an Effective Shift Report Jennifer Aycock, Jeanne Bennett, Rachelle Bertini, Jacquelyn Browne, Rachel Wirginis OU College of Nursing - Career Mobility

2. Identification of Problem Hand-off�s occur frequently Inconsistencies exist in hand-off methods Communication failures source of adverse events Cost associated with gaps in communication May result in sentinel events Ensuring continuity and consistency of information flow between health providers is one strategy of preventing adverse events and ensuring patient safety. Nurses play a pivotal role in healthcare, as they provide care to patients on a 24 hour basis. This places crucial importance on optimizing handoff communication strategies. Despite the frequency of handoff communication, minimal guidelines exist to facilitate effective practice. Handoff communication, aka shift report, occurs frequently, @ change of shift, 2 or more x day, 7 days per week. While shift report occurs frequently and is an important nursing responsibility, inconsistencies exist. There are multiple methods of shift report including verbal, taped, and written to name a few. Communication failures are identified as a source of adverse events, and Joint Commission reported that 70% of all sentinel events are caused by gaps in communication. We were unable to find statistical data regarding the cost associated with ineffective handoffs, however, research shows that gaps in communication lead to adverse and sentinel events, which end up costing an organization. Research also shows that good communication leads to nurse retention, which saves the cost it takes to frequently hire/train new nurses. Ensuring continuity and consistency of information flow between health providers is one strategy of preventing adverse events and ensuring patient safety. Nurses play a pivotal role in healthcare, as they provide care to patients on a 24 hour basis. This places crucial importance on optimizing handoff communication strategies. Despite the frequency of handoff communication, minimal guidelines exist to facilitate effective practice. Handoff communication, aka shift report, occurs frequently, @ change of shift, 2 or more x day, 7 days per week. While shift report occurs frequently and is an important nursing responsibility, inconsistencies exist. There are multiple methods of shift report including verbal, taped, and written to name a few. Communication failures are identified as a source of adverse events, and Joint Commission reported that 70% of all sentinel events are caused by gaps in communication. We were unable to find statistical data regarding the cost associated with ineffective handoffs, however, research shows that gaps in communication lead to adverse and sentinel events, which end up costing an organization. Research also shows that good communication leads to nurse retention, which saves the cost it takes to frequently hire/train new nurses.

3. PICO Question Does evidence/research support traditional face-to-face hand-off/report or a combination of hand-off methods between nurses as most effective? Our PICO question is�Our PICO question is�

4. PICO Question Population: Nursing staff Intervention: Traditional face-to-face hand-offs/report Comparison: Combination of hand-off methods Outcome: Most effective report To break down our PICO question, the population of interest is nursing staff. Our intervention of interest is traditional face-to-face hand-offs or shift report. We are comparing various hand-off methods, and we are interested in finding the most effective method of report.To break down our PICO question, the population of interest is nursing staff. Our intervention of interest is traditional face-to-face hand-offs or shift report. We are comparing various hand-off methods, and we are interested in finding the most effective method of report.

5. Definitions Traditional face-to-face hand-off Verbal Verbal and written Combination of other hand-off methods Computerization Taped Standardized/pre-printed form Bedside/walking rounds There are various methods of shift report. Traditional face-to-face includes verbal or verbal with a written supplement. Non-traditional methods include computerized handoff, taped, standardized form, and bedside or walking rounds.There are various methods of shift report. Traditional face-to-face includes verbal or verbal with a written supplement. Non-traditional methods include computerized handoff, taped, standardized form, and bedside or walking rounds.

6. Factors that Contribute to Ineffective Shift Report Communication barriers Lack of standardization Equipment Issues Environmental Issues Lack or misuse of time Lack of training or education Human factors There are several factors that contribute to ineffective shift reports. Communication barriers, which include omissions, incorrect information, failure to understand which info. is essential, language barriers. A lack of standardization exists, for example, forms aren�t standardized for units, there are a lack of adequate policies relevant to hand-offs and a lack of financial resources. Equipment issues may occur when utilizing technology such as computers, audiotapes, or voicemail. Environmental issues such as interruptions, distractions, too much noise, and multitasking during report are also barriers. Other factors include a lack or misuse of time and lack of training or no training. Human factors involved include stressful or overlong shifts (which cause fatigue and forgetfulness) and high nurse turnover. � There are several factors that contribute to ineffective shift reports. Communication barriers, which include omissions, incorrect information, failure to understand which info. is essential, language barriers. A lack of standardization exists, for example, forms aren�t standardized for units, there are a lack of adequate policies relevant to hand-offs and a lack of financial resources. Equipment issues may occur when utilizing technology such as computers, audiotapes, or voicemail. Environmental issues such as interruptions, distractions, too much noise, and multitasking during report are also barriers. Other factors include a lack or misuse of time and lack of training or no training. Human factors involved include stressful or overlong shifts (which cause fatigue and forgetfulness) and high nurse turnover. �

7. Nursing Handoffs: A Systematic Review of the Literature (Riesenberg, L.A., et al., 2010) Systematic Review: Analyzed 20 qualifying articles published between 1987 to 2008 Findings: Characteristics of effective hand-off Communication skill Standardization strategies Technologic solution Environmental strategies Training and education A literature search discovered over 2,600 articles between 1987-2008 that related to nursing hand-offs. A well defined systematic review was conducted, and 20 articles met the inclusion criteria and quality standards. Analysis of these 20 articles revealed that there was no scientific evidence that one type of hand-off was superior to another. There was however a consensus reached about the favorable characteristics for an effective hand-off. These include effective communication skills such as clear and concise content, standardized processes and tools to guide the content and flow of the handoff, technological advances such as computerized records, a quiet environment free of distractions, and proper training of these processes and skills. A literature search discovered over 2,600 articles between 1987-2008 that related to nursing hand-offs. A well defined systematic review was conducted, and 20 articles met the inclusion criteria and quality standards. Analysis of these 20 articles revealed that there was no scientific evidence that one type of hand-off was superior to another. There was however a consensus reached about the favorable characteristics for an effective hand-off. These include effective communication skills such as clear and concise content, standardized processes and tools to guide the content and flow of the handoff, technological advances such as computerized records, a quiet environment free of distractions, and proper training of these processes and skills.

8. Nursing Handoffs: Continued Limitations: Lack of quality research Not all QI projects reported Conclusions: Starting point for improving hand-offs Recommend further research (Riesenberg, 2010) The systematic review was limited by a lack of high quality research articles on this topic. A minor theoretical concern was raised that QI projects with negative outcomes often go unpublished. The overall conclusion of the review was that the current literature gives us some strategies for improving hand-offs. Higher quality studies with outcomes data were recommended by the authors. The systematic review was limited by a lack of high quality research articles on this topic. A minor theoretical concern was raised that QI projects with negative outcomes often go unpublished. The overall conclusion of the review was that the current literature gives us some strategies for improving hand-offs. Higher quality studies with outcomes data were recommended by the authors.

9. Hospitalist Handoffs: A Systematic Review and Task Force Recommendations (Arora, V.M., et al., 2009) Systematic Review: Analyzed 10 articles from 1995 to 2005 Findings: Supports face-to-face verbal with structured template Task force recommendation formulated The next systematic review we�re going to discuss analyzed ten articles from 1995 to 2005 that met review criteria. Three of the studies were nurse handoffs, and 7 were between hospitalists. As a result of the review�s findings, recommendations include using face-to-face verbal handoffs supplemented with written form or technological solutions. A standardized template or tool was recommended to record patient information during the handoff. Content recommendations included highlighting pertinent data and action items such as pending tests, labs and treatments. Once again, educating and training staff on the preferred hand-off process was important to the quality of the hand-offs. � The next systematic review we�re going to discuss analyzed ten articles from 1995 to 2005 that met review criteria. Three of the studies were nurse handoffs, and 7 were between hospitalists. As a result of the review�s findings, recommendations include using face-to-face verbal handoffs supplemented with written form or technological solutions. A standardized template or tool was recommended to record patient information during the handoff. Content recommendations included highlighting pertinent data and action items such as pending tests, labs and treatments. Once again, educating and training staff on the preferred hand-off process was important to the quality of the hand-offs. �

10. Hospitalist Handoffs: Continued Limitations: Small studies Few controlled interventions Technology solutions not standardized Only one study included patient outcomes Conclusions: Began to standardize hand-offs Starting point for promoting safe hand-offs (Arora, 2009) Limitations included small sample sizes in many of the studies. Most of the studies were observational, so few had any controlled interventions. Various technologies and tools were used in the studies, making comparisons between studies more difficult. Only one study looked at patient outcomes. The overall conclusion of this review was that hand-offs should be standardized and have verbal and written components in order to improve patient hand-offs. Limitations included small sample sizes in many of the studies. Most of the studies were observational, so few had any controlled interventions. Various technologies and tools were used in the studies, making comparisons between studies more difficult. Only one study looked at patient outcomes. The overall conclusion of this review was that hand-offs should be standardized and have verbal and written components in order to improve patient hand-offs.

11. Assessing the Quality of Patient Handoffs at Care Transitions (Manser, T. et al., 2009) Pilot Study 126 patient handoffs in three clinical settings Developed tool for rating quality of handoffs Findings/Conclusions Information transfer Shared understanding Working atmosphere Rating tool useful in future studies This study by Manser was an experimental study that developed a tool to rate the quality of handoffs. The study looked at 126 patient hand-offs on three units of the study hospital. Researchers found that three themes emerged through correlation and regression analysis that were statistically significant. When measured, these three themes showed good predictive value of the quality of a hand-off. The first theme was information transfer, which was the organization and content of the hand-off. The second theme was shared understanding, or the quality of the communication between the staff performing the handoff. Lastly, the working atmosphere or environment was shown to influence the quality of hand-offs. Privacy, minimal distractions and ample time to conduct the hand-off were all desirable elements for a quality hand-off. In conclusion, the hand-off rating tool developed in this study should prove useful in future research on hand-offs. This study by Manser was an experimental study that developed a tool to rate the quality of handoffs. The study looked at 126 patient hand-offs on three units of the study hospital. Researchers found that three themes emerged through correlation and regression analysis that were statistically significant. When measured, these three themes showed good predictive value of the quality of a hand-off. The first theme was information transfer, which was the organization and content of the hand-off. The second theme was shared understanding, or the quality of the communication between the staff performing the handoff. Lastly, the working atmosphere or environment was shown to influence the quality of hand-offs. Privacy, minimal distractions and ample time to conduct the hand-off were all desirable elements for a quality hand-off. In conclusion, the hand-off rating tool developed in this study should prove useful in future research on hand-offs.

12. Review: Bringing Patient Safety to the Forefront through Structured Computerization During Clinical Handover (Matic, et al., 2010) Integrative Literature Review: 126 articles reviewed Findings/Conclusions: Good communication link to safety Incomplete information increases risk of adverse events More research is necessary The next study takes a look at the use of computers during handoff and is titled� This was an integrative literature review that critically examined, the methods and modes of delivery of handoff used in contemporary health care settings and explored the feasibility of a computerized handoff system for improving patient safety. A total of 304 sources were retrieved and 126 published articles were identified for the review. Findings of the literature review supported the value of communication strategies during shift-to-shift handoff and identified ambiguities and incomplete information which can increase the risks of adverse events. In conclusion, given the importance of effective communication, it is imperative that clinical handoff undergo increased scrutiny, development and research. The next study takes a look at the use of computers during handoff and is titled� This was an integrative literature review that critically examined, the methods and modes of delivery of handoff used in contemporary health care settings and explored the feasibility of a computerized handoff system for improving patient safety. A total of 304 sources were retrieved and 126 published articles were identified for the review. Findings of the literature review supported the value of communication strategies during shift-to-shift handoff and identified ambiguities and incomplete information which can increase the risks of adverse events. In conclusion, given the importance of effective communication, it is imperative that clinical handoff undergo increased scrutiny, development and research.

13. Translating an Evidence-Based Protocol for Nurse-to-Nurse Shift Handoff (Dufalt,M., et al., 2010) Traditional Literature Review Reviewed nine studies Inpatient facilities, various designs Findings/Conclusions: Eight recommendations for establishing protocols Developed standardized, patient- centered approach They looked at nine studies that were conducted in in-patient facilities utilizing various designs regarding change of shift hand-offs. Findings of the study include the utilization of research roundtables and focus groups to identify eight recommendations for establishing best-practice protocol for nurse-to-nurse shift hand-offs. In conclusion, the development of a standardized approach to hand-off was developed. � They looked at nine studies that were conducted in in-patient facilities utilizing various designs regarding change of shift hand-offs. Findings of the study include the utilization of research roundtables and focus groups to identify eight recommendations for establishing best-practice protocol for nurse-to-nurse shift hand-offs. In conclusion, the development of a standardized approach to hand-off was developed. �

14. Pilot Study to Show the Loss of Data in Nursing Handover (Pothier, D., et al., 2005) Pilot Study: 12 simulated patients over five hand-over cycles Findings: Loss of data Effect of importance of data Effect of category of data Incorrect data as substitute The next study is a little different, it is a pilot study titled Pilot Study� It was a simulated handoff scenario was constructed that involved one-to-one handoff of patients between 2 nurses. The scenario included 12 fictitious patients, and there were 3 study groups that utilized different handoff methods: verbal, written, and pre-prepared form. The purpose of this study was to document how much data is lost in consecutive handoffs. All three groups lost data, verbal lost the most and the pre-prepared sheet had the least amount of data loss. The effect of data category was that the medical history and demographics were the least likely to suffer from data loss. The verbal group substituted incorrect data for issues that were not present. This did not occur with the other methods. The next study is a little different, it is a pilot study titled Pilot Study� It was a simulated handoff scenario was constructed that involved one-to-one handoff of patients between 2 nurses. The scenario included 12 fictitious patients, and there were 3 study groups that utilized different handoff methods: verbal, written, and pre-prepared form. The purpose of this study was to document how much data is lost in consecutive handoffs. All three groups lost data, verbal lost the most and the pre-prepared sheet had the least amount of data loss. The effect of data category was that the medical history and demographics were the least likely to suffer from data loss. The verbal group substituted incorrect data for issues that were not present. This did not occur with the other methods.

15. Pilot Study: Continued Conclusion: Style of handover important role in accuracy Recommend combination of verbal with prepared sheet More research is necessary (Pothier, 2005) In conclusion, the study confirmed that the style of handover plays an important part in the accuracy of the handover. The researchers recommend a combination of verbal with a pre-prepared form, however more research is suggested. � In conclusion, the study confirmed that the style of handover plays an important part in the accuracy of the handover. The researchers recommend a combination of verbal with a pre-prepared form, however more research is suggested. �

16. Transfer of Accountability: Transforming Shift Handover to Enhance Patient Safety (Alvarado, K. et al., 2006) Pilot Study: Two clinical inpatient units/number of nurses unknown Two phases: survey distributed, guidelines developed Findings: Nurses preferred written tool Conclusion: Standardization improves communication Now we�ll discuss a pilot study involving 2 clinical inpatient units: a general medical and obstetric floor, however the number of nurses was unknown. The study was comprised of 2 phases, in the first, a survey was distributed to determine what form of shift report nurses were utilizing, then report guidelines were developed and implemented. It was found that nurses preferred utilizing a written form that was tailored to their specific unit. In conclusion, use of a written form improves the effectiveness of communication/report. Now we�ll discuss a pilot study involving 2 clinical inpatient units: a general medical and obstetric floor, however the number of nurses was unknown. The study was comprised of 2 phases, in the first, a survey was distributed to determine what form of shift report nurses were utilizing, then report guidelines were developed and implemented. It was found that nurses preferred utilizing a written form that was tailored to their specific unit. In conclusion, use of a written form improves the effectiveness of communication/report.

17. The Tangible Handoff: A Team Approach for Advancing Structured Communication in Labor and Delivery (Block, M. et al., 2010) Pilot Study: 13 random nursing shifts on L&D floor Tool developed and tested Findings/Conclusions: 90% compliance Joint Commission National Patient Safety Goal This was a pilot study in which a tool was developed and utilized on 13 random nursing shifts on a labor and delivery floor. The tool developed uses SBAR (situation, background, assessment, and recommendation) format; it guides nurses through a structured verbal report with the acknowledgment of transfer of care, and is updated each shift. This tool provides �essential� information about the patient. It was found that nurses felt the tool was very �organized,� and 90% of nurses complied with using the tool. In conclusion, this tool addresses Joint Commission requirements in standardizing handoffs with an opportunity to ask and respond to questions. � This was a pilot study in which a tool was developed and utilized on 13 random nursing shifts on a labor and delivery floor. The tool developed uses SBAR (situation, background, assessment, and recommendation) format; it guides nurses through a structured verbal report with the acknowledgment of transfer of care, and is updated each shift. This tool provides �essential� information about the patient. It was found that nurses felt the tool was very �organized,� and 90% of nurses complied with using the tool. In conclusion, this tool addresses Joint Commission requirements in standardizing handoffs with an opportunity to ask and respond to questions. �

18. Implementing an Electronic Change-of-Shift Report Using Transforming Care at the Bedside, Processes and Methods (Nelson, B.A., et al., 2010) Pilot Study: 32 bed unit Transforming Care at the Bedside (TCAB) model implemented Findings/Conclusions: Improved nurse satisfaction Perceived increase in efficiency of report Length of shift report reduced Unit cost reduced This was a pilot study that involved a 32 bed GI-surgical-oncology unit. The �Transforming Care At The Bedside Model� was implemented, which included the use of a computer document on which the nurses would type pertinent info throughout the day, instead of waiting to end of day to collect data for report. The document would be printed, and given to oncoming nurse for shift report. Findings and conclusions included increased nurse satisfaction, less opportunity for error/omissions with TCAB model, and more efficient report which reduced unit cost. This was a pilot study that involved a 32 bed GI-surgical-oncology unit. The �Transforming Care At The Bedside Model� was implemented, which included the use of a computer document on which the nurses would type pertinent info throughout the day, instead of waiting to end of day to collect data for report. The document would be printed, and given to oncoming nurse for shift report. Findings and conclusions included increased nurse satisfaction, less opportunity for error/omissions with TCAB model, and more efficient report which reduced unit cost.

19. Using a Computerized Sign-Out System to Improve Physician-Nurse Communication (Sidlow, R., et al., 2006) Pilot Study: 20 nurses at Jacobi Medical Center, New York Nurses given access to physicians computerized sign-out reports Findings/Conclusions: 19/20 nurses agreed report improved patient care Improved communication and morale More research needed An electronic sign-out program was implemented for medical residents at Jacobi Medical Center. It was so successful that 18 months later, a pilot study was initiated to explore benefits of allowing nurses access to this sign-out data. Nurses were given a print out of the sign-out information and asked to use it as a guide for their report. Later, a questionnaire was given to participating nurses. Findings: 19/20 nurses agreed that using the resident sign-out program positively affected their ability to care for their patients. It also improved nurses� understanding of reason for patient�s admission, improved physician-nurse communication, and raised morale. In conclusion, further efforts should be aimed at supporting data sharing between physicians and nurses, and further studies are warranted to examine the impact of these interventions on patient safety outcomes. An electronic sign-out program was implemented for medical residents at Jacobi Medical Center. It was so successful that 18 months later, a pilot study was initiated to explore benefits of allowing nurses access to this sign-out data. Nurses were given a print out of the sign-out information and asked to use it as a guide for their report. Later, a questionnaire was given to participating nurses. Findings: 19/20 nurses agreed that using the resident sign-out program positively affected their ability to care for their patients. It also improved nurses� understanding of reason for patient�s admission, improved physician-nurse communication, and raised morale. In conclusion, further efforts should be aimed at supporting data sharing between physicians and nurses, and further studies are warranted to examine the impact of these interventions on patient safety outcomes.

20. The Content and Context of Change of Shift Report on Medical and Surgical Units (Staggers, N., et al., 2009) Observational Study Reports audio taped and observed 53 patients involving 38 nurses Findings The dance of report Just the facts Professional nursing practice Lightening the load Conclusion Provides sense of content/context of report Further research necessary Because change of shift report is a commonly occurring handoff that can contribute to gaps in care, this study was conducted to describe the content and context of change of shift report on medical and surgical units. Reports were audio-taped and observed at several facilities in the western U.S., and involved 53 patients and 38 nurses. Findings: The Dance of Report � (33% of report) Which reflected the �choreography� of report, or the movement between report partners. This theme included full interruptions, distractions, and losing one�s train of thought. Just the Facts � (30%) Involved nurses exchanging non-controversial, factual patient data, for example, patient�s name, age, and room number. Professional nursing practice � (25%) Included information related to nursing actions, knowledge, reasoned judgments combined with care decisions. Lightening the Load � (13%) Reflected thoughtfulness toward other staff, teamwork, and bonds between nurses. Conclusions: This study provides a sense of the content and context of report. These researchers suggest future research should evaluate methods to improve report, and, more specifically, ways to decrease interruptions. Because change of shift report is a commonly occurring handoff that can contribute to gaps in care, this study was conducted to describe the content and context of change of shift report on medical and surgical units. Reports were audio-taped and observed at several facilities in the western U.S., and involved 53 patients and 38 nurses. Findings: The Dance of Report � (33% of report) Which reflected the �choreography� of report, or the movement between report partners. This theme included full interruptions, distractions, and losing one�s train of thought. Just the Facts � (30%) Involved nurses exchanging non-controversial, factual patient data, for example, patient�s name, age, and room number. Professional nursing practice � (25%) Included information related to nursing actions, knowledge, reasoned judgments combined with care decisions. Lightening the Load � (13%) Reflected thoughtfulness toward other staff, teamwork, and bonds between nurses. Conclusions: This study provides a sense of the content and context of report. These researchers suggest future research should evaluate methods to improve report, and, more specifically, ways to decrease interruptions.

21. Can Technology Improve Intershift Report? What the Research Reveals (Strople, B., et al., 2006) Literature Review of 64 articles Findings/Conclusions: Verbal and taped have similar faults Little data available on computerized report Real time documentation Efficient reports increase patient-care time This was a literature review that found verbal and taped report have similar faults. These include personal opinions often given that have little to do with patient care, for example, �Room 8 is a problem patient�� Data omissions or inaccuracies: incorrect information passed on in report, for example, dialysis fistula reported on the right side, when was on the left side in the patient� Computer report: There is little data on using computer only report. They also encourage real time documentation at the bedside with use of PDA, because �computers on wheels� are seen by nurses as cumbersome and inconvenient. Streamlining report leads to increased patient care time, which reduces complications. � This was a literature review that found verbal and taped report have similar faults. These include personal opinions often given that have little to do with patient care, for example, �Room 8 is a problem patient�� Data omissions or inaccuracies: incorrect information passed on in report, for example, dialysis fistula reported on the right side, when was on the left side in the patient� Computer report: There is little data on using computer only report. They also encourage real time documentation at the bedside with use of PDA, because �computers on wheels� are seen by nurses as cumbersome and inconvenient. Streamlining report leads to increased patient care time, which reduces complications. �

22. Barriers and Facilitators to Nursing Hand-offs: Recommendations for Redesign (Welsh, C.A. et al., 2010) Pilot Study: 20 nurses at large medical center Findings: 6 Barriers Too much information Too little information Inconsistent quality Limited opportunity for questions Equipment malfunction Interruptions This was a pilot study interviewing 20 nurses at Midwestern Veterans Administration Medical Center. It was found that there are 6 barriers and 4 facilitators to an effective shift report. Barriers include: 1. Too much information: lengthy reports with irrelevant information. 2. Too little information, for example, incomplete or missing information which caused nurses to spend extra time looking for information from places like the chart. 3. Inconsistent quality: found that quality depended on the nurse giving report. 4. Limited opportunity to ask questions: sometimes oncoming nurses didn�t have any contact with outgoing nurses, for example, with taped or written report. 5. Equipment malfunctions 6. Interruptions. � This was a pilot study interviewing 20 nurses at Midwestern Veterans Administration Medical Center. It was found that there are 6 barriers and 4 facilitators to an effective shift report. Barriers include: 1. Too much information: lengthy reports with irrelevant information. 2. Too little information, for example, incomplete or missing information which caused nurses to spend extra time looking for information from places like the chart. 3. Inconsistent quality: found that quality depended on the nurse giving report. 4. Limited opportunity to ask questions: sometimes oncoming nurses didn�t have any contact with outgoing nurses, for example, with taped or written report. 5. Equipment malfunctions 6. Interruptions. �

23. Barriers and Facilitators: Continued Findings: 4 facilitators �Pertinent� Content Notes Face-to-face interaction Structured form/checklist Conclusions: Shift report must be organized Suggest standardized format Improves continuity of care and patient safety More research needed (Welsh, 2010) The four facilitators are as follows: 1. Pertinent content, which means content that is unit & patient specific, for example, abnormal vitals, labs, iv fluids, code status, etc. 2. Notes: Help nurses recall important information. 3. Face-to-face interaction between the outgoing on oncoming nurse allows for an opportunity to ask questions which results in an increased trust in information being given, and an opportunity for real time feedback on accuracy of report. 4. Structured form/checklist: nurses supported use of a checklist that includes content that is relevant to its users and varies based on the type of unit worked. Conclusion: Report must be organized and standardized based on unit needs and is relevant to improve continuity of care. Training needed for efffective hand-offs The four facilitators are as follows: 1. Pertinent content, which means content that is unit & patient specific, for example, abnormal vitals, labs, iv fluids, code status, etc. 2. Notes: Help nurses recall important information. 3. Face-to-face interaction between the outgoing on oncoming nurse allows for an opportunity to ask questions which results in an increased trust in information being given, and an opportunity for real time feedback on accuracy of report. 4. Structured form/checklist: nurses supported use of a checklist that includes content that is relevant to its users and varies based on the type of unit worked. Conclusion: Report must be organized and standardized based on unit needs and is relevant to improve continuity of care. Training needed for efffective hand-offs

24. Recommended Interventions Improve training Develop a standardized form Unit specific Utilize form in combination with traditional face-to-face report Allow an opportunity for questions These include improved training, develop a standardized form that is unit specific, use this form in conjunction with face-to-face report, and allow an opportunity for questions. However, more research is needed as pratice guidelines have yet to be identified. � These include improved training, develop a standardized form that is unit specific, use this form in conjunction with face-to-face report, and allow an opportunity for questions. However, more research is needed as pratice guidelines have yet to be identified. �

25. Suggestions for further study More rigorous scientific methodology Studies focusing on systems factors, human performance, and effectiveness of structured protocols Outcomes data needed to determine if one handoff technique is superior to another Support collaborative data-sharing between physicians and nurses Information is limited, and further research is needed to enhance handoff practices. It is imperative that clinical handover undergo increased scrutiny and research. High quality outcomes studies are needed that focus on systems factors, human performance, and the effectiveness of protocols and interventions. Future studies are needed to examine the impact of these interventions on patient safety outcomes. Further efforts should be aimed at developing and supporting data-sharing between physicians and nurses. The findings can serve as a starting point for improving the quality of nursing handoffs. � Information is limited, and further research is needed to enhance handoff practices. It is imperative that clinical handover undergo increased scrutiny and research. High quality outcomes studies are needed that focus on systems factors, human performance, and the effectiveness of protocols and interventions. Future studies are needed to examine the impact of these interventions on patient safety outcomes. Further efforts should be aimed at developing and supporting data-sharing between physicians and nurses. The findings can serve as a starting point for improving the quality of nursing handoffs. �

26. References Alvarado, K., Lee, R., Christoffersen, E., Fram, N., Boblin, S., Poole, N., Lucas, J., & Forsyth, S. (2006). Transfer of Accountability: Transforming shift handover to enhance patient safety. Healthcare Quarterly, 9, 75-79. Arora, V. M., Manjarrez, E., Dressler, D. D., Basaviah, P., Halasyamani, L., & Kripalani, S. (2009). Hospitalist handoffs: A systematic review and taskforce recommendations. Journal of Hospital Medicine, 4(7), 433-440.

27. References Block, M.D., Ehrenworth, J.F., Cuce, V.M., Ng�ang�a, N., Weinbach, J., Saber, S.B., . . . & Schlesinger, M.D. (June 2010). The tangible handoff: A team approach for advancing structured communication in labor and delivery. The Joint Commission Journal on Quality and Patient Safety, 36(6), 282-288. Dufalt, M., Duquette, C.E., Ehmann, J., Hehl, R., Lavin, M., Martin, V., &. . . Willey, C. (2010). Translating an evidence-based protocol for nurse-to-nurse shift handoffs. Worldviews on Evidence-Based Nursing, 7(2), 59-75.

28. References Manser, T., Foster, S., Gisin, S., Jaeckel, D., & Ummenhofer, W. (2010). Assessing the quality of patient handoffs at care transitions. British Medical Journal, Quality and Safety, 19, 1-5. Matic, J., Davidson, P.M., & Salamonson, Y. (2010). Review: Bringing patient safety to the forefront through structured computerisation during clinical handover. Journal of Clinical Nursing, 20, 184-189. Nelson, B.A., Massey, R. (2010). Implementing an electronic change-of-shift report using transforming care at the bedside processes and methods. Journal of Nursing Administration, 40(4), 162-168.

29. References Pothier, D. Monteiro, P., Mooktiar, M., & Shaw, A. (2005). Pilot study to show the loss of important data in nursing handover. British Journal of Nursing, 14(20), 1090-1093. Riesenberg, L., Leitzsch, J. & Cunningham, J. (2010). Nursing Handoffs: A systematic review of the literature. American Journal of Nursing, 110(4), 24-34. Sidlow, R., Katz-Sidlow, R. J. (2006). Using a computerized sign-out system to improve physician-nurse communication. Joint Commission Journal on Quality and Patient Safety, 32(1), 32-3.

30. References Staggers, N., & Jennings, B.M. (2009). The content and context of change of shift report on medical and surgical units. The Journal of Nursing Administration, 39(9), 393-398. Strople, B., & Ottani, P. (2006). Can technology improve intershift report? What the research reveals. Journal of Professional Nursing, 22, 197 � 204. Welsh, C.A., Flanagan, M.E., & Ebright P. (2010). Barriers and facilitators to nursing handoffs: Recommendations for redesign. Nursing Outlook, 58(3), 148-154.

31. Questions