Patients in the hospital require multiple caregivers. When these caregivers are ending their shifts, another healthcare provider must assume responsibility for the patient. While it is understood that healthcare providers must eventually transfer care to another person, does a structured report improve consistency of handoff? In these cases, is standard telephone or written report enough to safely transfer care, or does report at the bedside or in-person with another healthcare provider help to improve consistency?
Without proper communication, we are at risk for major healthcare errors. During this crucial time in a patient’s stay, an ineffective handoff can lead to a poor patient experience and have a direct impact on safety and important clinical outcomes (Bruton, Norton, Smyth, Ward, & Day, 2016).
Stewart & Hand report patient handoff is a time when communication barriers can lead to frequent errors. In order to combat these barriers, SBAR was introduced to healthcare in 2002 (2017). SBAR stands for Situation-Background-Assessment-Recommendation and is a common tool used for patient handoff in the United States.
While there are many forms of SBAR, it is unclear which communication style is preferable to increase patient safety. In order to determine which style is more clinically indicated, a literature review was conducted.
Does bedside handoff between nurses at transfer of care improve structured consistency of handoff compared to telephone report?
P- Nurses at transfer of care handoff
I- Bedside handoff for patients having a change of care
C- Standard unstructured telephone report or written report
O- Improve structured consistency between nurses during critical period in patient’s stay
The PubMed database was used to search publications related to the PICO question, which involves nurses giving SBAR bedside handoff at transfer of level of care as opposed to standard telephone report. In PubMed, the search term used was “bedside handoff” and yielded 14 results, all of which were published in the last six years. Looking at the search details, no MeSH terms were used. When attempting to locate a MeSH term for bedside handoff, only one related to nursing and its subspecialties was found. Using “report” as a MeSH term, it resulted with “teaching rounds” but was primarily related to medicine and not nursing. “Bedside report” yielded 1,566 results compared to the initial 14 results, and when limiting to full text within 10 years narrowed it down to 409 results. Many of the results were relevant, however there were results that only included studies about a variety of actual reports, not bedside handoff. As the word “handoff” is fairly new to nursing, other search terms produced more results (see Appendix A, Table 1). After a PubMed search, the same searches were repeated with CINAHL, the Cochrane Database of Systematic Reviews, and MEDLINE. Before the PRISMA diagram was completed, search terms such as “nursing” or “nurse” we needed in order to filter results.
Exclusion criteria included articles solely about physician handoff, those not relative to handoff, those in languages other than English, and those with no abstract available. After further review, expanded exclusion criteria included those missing full text pages, information, or diagrams, as well as those determined to be anecdotal or editorials (see Appendix D, Figure 1).
Upon closer inspection of results, it was determined that many articles weren’t studies at all. Upon a full text review, it was evident many were more anecdotal, or editorials, when in fact they were described as studies or scholarly articles. Performing the data extraction aided in the awareness of the important of search terms and full text review when performing a systematic review. Eventually, many of the articles needed to be discarded. Articles that were initially planned on applying from the start turned out to be irrelevant or unable to fit the criteria to answer the PICO question. The author and the peer reviewer found a consensus could be reached if articles were discussed from the perspective of a random non-nurse reader. If it could be determined that a non-nurse could understand the article extraction, then it was considered for inclusion.
After full text review and quality analysis, three studies were deemed appropriate (see Appendices B and C, Tables 2 and 3).
Joffe et al. (2013) described a randomized trial using a simulated on-call setting between physicians and nurses. This setting utilized SBAR in a telephone setting versus standard telephone report. Randmaa, Martensson, Swenne, & Engstrom (2014) employed a prospective intervention study with a comparison group using pre-assessments and post-assessments with SBAR. Cornell, Gervis, Yates, & Vardaman (2014) performed baseline observation of shift reports’ tasks, tools, and locations, before implementing SBAR protocols on paper and an eventual electronic version.
Participants for the combined studies included primarily nurses and physicians in hospital settings. The type of nursing unit varied with each study, however all were inpatient settings.
Joffe et al. devised a study consisting of 22 pairs of registered nurses and internal medicine physicians. Both the nurses and physicians were currently practicing on inpatient general medical wards. The years of experience and the ages of the participants were not provided.
Randmaa et al. included participants consisting of registered nurses, licensed practical nurses, and physicians working in operating rooms, intensive care units, and post-anesthesia care units in two hospitals sharing the same management. Participants were primarily female (85%) and average nursing experience was 17.5 years.
Cornell et al. reviewed a 48-bed medical surgical unit in a suburban hospital in the southern United States. The number of nurses participating was 36, with the average participant aged 37.2 years. Experience in nursing spanned 6 months to 36 years, with an average of 8.9 years. The participants included staff nurses, nursing leadership, and case managers, as well as pharmacy and social work. Patients, family members, and physicians were not included in the observations.
Characteristics of the Studies
Joffe et al.
Joffe et al. presented each participating nurse with six written scenarios: three that would be communicated using a specific SBAR format and three that would be communicated without SBAR. All nurses had access to the same medical chart, including notes, lab results, and medications. The authors used actual patient records that were modified to fit the clinical scenarios. Nurses participating were allowed to ask questions about the patient if something was unclear, however if the answer was outside of a predetermined scripted answer, then information was not given to the participants. The situation and background sections in the SBAR format were analyzed in the form of defined verbal cues. Nurses were not prompted to deliver specific situational and background information, how the authors did evaluate the ability of the nurse to do so. The control and experimental reports were evaluated using a set of data elements devised by an expert panel as it applied to SBAR. The data was calculated using a ratio formula of data elements communicated to total number of relevant data elements. After the experiment was completed, a total of 17 pairs were deemed appropriate to analyze after certain exclusions. This led to a data set of 92 phone calls, including 43 SBAR handoffs and 49 control handoffs.
The authors found there was no difference in the rate of communicated situational cues when comparing SBAR calls to the control calls, however the authors did find using the SBAR form was associated with a higher rate of communicating the background. Incorrect information was delivered to physicians regardless of the tool used. Nurses reported wrong information regarding background and situation about 5% of the time.
Randmaa et al.
Randmaa et al. disseminated 316 questionnaires to all staff participating in the study. SBAR communication tools were implemented with the assistance of management. An introductory period was held, and on-site education was delivered regarding appropriate SBAR communication. Reference tools were distributed to staff to help facilitate SBAR handoff. All participants across all departments had access to structured SBAR handoff reference tools. Questionnaires were collected before implementation and then again six months afterwards. The ICU Nurse-Physician Questionnaire tool was used to measure the communication between the nurses and physicians. The authors also used the Safety Attitudes Questionnaire (SAQ) and Spritzer’s empowerment scale to measure attitudes of staff members and their empowerment to use SBAR. Authors then collected data from safety and incident reporting systems during the year prior and after SBAR implementation.
The number of respondents to initial questionnaires was 139 of 194 (72%) in the SBAR group and 91 of 122 (75%) in the control group; with the follow-up rate after six months decreasing to 100 of 139 (72%) and 69 of 91 (76%) respectively. The authors reported no statistically significant differences between the SBAR group and control groups at baseline regarding age, sex, nursing experience, and years employed. However, the authors did find during the baseline analysis there were significantly higher scores in the control group on teamwork climate, safety climate, job satisfaction, working conditions, and communication accuracy. After implementation, the communication accuracy between groups improved significantly in the SBAR group (p=0.001). When changes were compared between the SBAR and control groups over time, the authors found no statistically significant differences. The SAQ reported the safety climate improved significantly (p=0.011) over time in the SBAR group, however no other statistically significant findings were found in the SAQ. When reviewing the safety and incident reports over time, it was found that the SBAR group led to a decrease in communication errors (p<0.0001) but not in the control group. The Spritzer’s empowerment scale yielded no significant changes or results.
Cornell et al.
The authors conducted direct observation of shift report using computers and checklists. Observers were nursing students trained to collect the data via classroom and practical methods. The four variables recorded were nurse tasks, tools
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