More Research Needed on Best Practices for Nursing Handoffs

Laurie Barclay, MD

April 08, 2010

April 8, 2010 — More research is needed on best practices for nursing handoffs, according to the results of a systematic review reported in the April issue of the American Journal of Nursing.

"Nursing handoffs occur when shifts change two or three times daily, seven days a week, yet despite the frequency of these events, there are few evidence-based standardized procedures to ensure that communication is managed effectively," lead author Lee Ann Riesenberg, PhD, RN, from the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia, Pennsylvania, said in a news release. "Errors in communication give rise to substantial clinical morbidity and mortality and, therefore, must be addressed."

To identify features of structured handoffs that have been effective, the investigators performed a systematic review of articles regarding nursing handoffs and a qualitative review of barriers to and strategies for effective handoffs. A search of English-language articles, published between January 1, 1987, and August 4, 2008, that focused on nursing handoffs in the United States yielded 2649 articles, of which 460, based on their title, were obtained for further review by trained abstractors.

Of 95 articles meeting the selection criteria, 55 (58%) were published between January 1, 2006, and August 4, 2008. Based on content analysis, the reviewers identified 8 major categories of barriers to effective handoffs and 7 major categories of strategies for effective handoffs.

Communication barriers were most prevalent, including lapses in or lack of communication, lengthy or irrelevant content, inaccurate recall of communicated information, illegible handwriting, and poor communication between nurses and physicians. Also cited were lack of supportive behaviors among nurses and poor peer relationships, problems related to standardization of tools and systems, and environmental issues such as poor lighting and distractions.

Strategies recommended for effective handoffs included improved standardization for communicating; for example:

  • use of computerized handoff systems,

  • tailoring report tools to specific departments, and

  • documenting transfer of responsibility.

Other strategies were:

  • addressing environmental problems,

  • providing training or education,

  • increasing staff involvement in the development of training programs,

  • allowing adequate time to plan for a new handoff process, and

  • linking the handoff process to performance evaluation.

Of 20 articles involving research on nursing handoffs, 17 (85%) had quality assessment scores (possible range, 1 - 16) of 8 or lower, and only 3 had scores higher than 10. Measures of handoff effectiveness were included in only 10 (50%) of the studies.

"Despite the well-known negative consequences of inadequate nursing handoffs, very little research has been done to identify best practices," the study authors write. "There is remarkable consistency in the anecdotally suggested strategies; but there is a paucity of evidence to support them. We call for high-quality studies of handoff outcomes that focus on systems factors, human performance, and the effectiveness of structured protocols and interventions."

Limitations of this review include lack of generalizability of information about barriers to and strategies for effective handoffs (e.g. a handoff strategy that works in the emergency department might not be effective for a surgical unit); anecdotal description of barriers and strategies; possible lack of inclusion of all relevant search terms, and possible publication bias.

"This study underscores the need for more research in this area," stated Maureen Shawn Kennedy, MA, RN, editorial director and interim editor-in-chief of the American Journal of Nursing in a news release. "Even though the Joint Commission is now requiring the standardization of patient handoffs, there's little evidence to indicate how to most effectively accomplish this process."

The review authors have disclosed no relevant financial relationships.

Am J Nurs. 2010;110:24-34. Abstract


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