Review of the literature

| January 5, 2016

Review of the literature

Order Description
Write a paper (1200 words) in which you analyze and appraise each of the (15) articles identified in Topic 1. Pay particular attention to evidence that supports the problem, issue, or deficit, and your proposed solution.
Hint: The Topic 2 readings provide appraisal questions that will assist you to efficiently and effectively analyze each article.
1.Why was the study done? Was there a clear explanation of the purpose of the study and, if so, what was it?
2.What is the sample size? Were there enough people in the study to establish that the findings did not occur by chance?
3. Are the instruments of the major variables valid and reliable? How were variables defined? Were the instruments designed to measure a concept valid (did they measure what the researchers said they measured)? Were they reliable (did they measure a concept the same way every time they were used)?
4.How were the data analyzed? What statistics were used to determine if the purpose of the study was achieved?
5.Were there any untoward events during the study? Did people leave the study and, if so, was there something special about them?
6.How do the results fit with previous research in the area? Did the researchers base their work on a thorough literature review?
7.What does this research mean for clinical practice? Is the study purpose an important clinical issue?
Refer to “Sample Format for Review of Literature,” “RefWorks,” and “Topic 2: Checklist.”
Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
Topic 2: Checklist
Review of Literature and Incorporating Theory


This checklist is designed to help students organize the weekly exercises/assignments to be completed as preparation for the final capstone project proposal. This checklist will also serve as a communication tool between students and faculty. Comments, feedback, and grading for modules 1-4 will be documented using this checklist.

Topic Task Completed Comments / Feedback Points
Review of Literature
• Analyze and appraise each of the 15 articles identified in module 1. (15 articles). _____ / 90
• Analysis organized using the sample provided in “Sample Format for Review of Literature.”
_____ / 10
Total _____/100
Incorporating Theory • Identified a theory that can be used to support proposed solution. _____ / 10
• Main components of theory described. _____ / 10
• Rationale for selecting theory provided. _____ / 10

• Discussed how theory works to support proposed solution.
_____ / 5
• Explained how theory will be incorporated into project. _____ / 5
Total _____/40

Original Article
Translating an Evidence-Based Protocol
for Nurse-to-Nurse Shift Handoffs
Marlene Dufault, RN, PhD, Cathy E. Duquette, RN, PhD, CPHQ, NEA-BC, Jeanne Ehmann, RN, MS, CPHQ,
Rose Hehl, RN, BS, Mary Lavin, RNP, MS, Valerie Martin, RN, MS, NE-BC, CHE, Mary Ann Moore, RN, BS,
Shirley Sargent, RN, MS, Patricia Stout, RNP, MS, Cynthia Willey, PhD
Purpose: Ineffective communication is the most frequently reported cause of sentinel events in U.S.
hospitals. Examining hospital processes and systems of communication, and standardizing communication
practices can reduce the risks to patients in the acute care environment. The purpose of this paper
is to describe the use of an innovative, translating-research-into-practice model to generate and test a
cost-effective, easy to use, best-practice protocol for nurse-to-nurse shift handoffs in a medium-sized
magnet-designated community hospital in the United States.
Theoretical Framework: Roger’s Diffusion of Innovations Theory was used as the overall framework
for the translational model with Orlando’s theory providing theoretical evidence for the best practice
Approach: Using the first three steps of the model, methods included: (1) identifying clinical problems
related to shift handoffs; (2) appraising and systematically evaluating the strength of theoretical, empirical,
and clinical evidence; and (3) translating this evidence into a best-practice patient-centered, standardized
protocol for nurse-to-nurse shift handoffs.
Conclusions/Implications: Meaningful clinician participation in the development of a standardized,
evidence-based, patient-centered approach to nurses’ change-of-shift handoffs was achieved. Using the
Collaborative Research Utilization Model can facilitate the integration of new knowledge both in the
clinical and academic community.
KEYWORDS translational research, evidence-based clinical policy, collaborative research utilization model,
nurse-to-nurse shift handoffs, shift report, handoffs, end-of-shift report, nurse-to-nurse report, bedside
shift report, computerized report
Worldviews on Evidence-Based Nursing 2010; 7(2):59–75. Copyright ©2010 Sigma Theta Tau International
Marlene Dufault, Professor, College of Nursing, University of Rhode Island, and Research Consultant, Newport Hospital, Kingston, RI; Cathy E. Duquette, Vice President,
Nursing and Patient Care Services Newport Hospital, Newport, RI; Jeanne Ehmann, Director, Performance Improvement & Evaluation, Newport Hospital, Newport, RI; Rose
Hehl, Staff Nurse, Newport Hospital, Newport, RI; Mary Lavin, Associate Clinical Professor, College of Nursing, University of Rhode Island, Kingston, RI; Valerie Martin,
Director of Surgical Services, Newport Hospital, Newport, RI; Mary Ann Moore, Staff Nurse, Newport Hospital, Newport, RI; Shirley Sargent, Doctoral Student & Research
Assistant, College of Nursing, University of Rhode Island, Kingston, RI; Patricia Stout, Associate Clinical Professor, College of Nursing, University of Rhode Island, Kingston,
RI; Cynthia Willey, Professor, College of Pharmacy, University of Rhode Island, Kingston, RI.
This project was funded by the Delta Upsilon Chapter-at-Large, Sigma Theta Tau International, and by The Nursing Foundation of Rhode Island. We wish to acknowledge the
contributions of the University of Rhode Island College of Nursing Class of 2008; Barbara Davis, Newport Hospital librarian; Jean Taft, RN, and the Newport Hospital nursing
staff who opened their practice to the eyes of research.
Address correspondence to Marlene Dufault, PhD, RN, College of Nursing, White Hall, University of Rhode Island, Kingston, RI 02881;
Accepted 23 January 2010
Copyright©2010 Sigma Theta Tau International
Worldviews on Evidence-Based Nursing Second Quarter 2010 59
Protocol for Nurse-to-Nurse Handoffs
Adverse events resulting from faulty communications
are a leading cause of death and injury in hospitals
in the United States, even though there is empirical evidence
to support interventions aimed at preventing their
occurrence. In recent years, experts in health care communications
research have speculated that many omissions
of relevant patient care and missing or incorrect communication
of patient information problems are related to a
lack of research-based standards in administrative protocols
and policies (National Quality Forum [NQF] 2005).
The NQF report recommends a standardized approach to
handoff communications as 1 of 30 high-priority practices
that have strong evidence base, can be generalized,
and are likely to benefit patient safety if implemented.
Such practices were derived from the Agency for Healthcare
Research and Quality’s (AHRQ), University of California
San Francisco-Stanford University Evidence-Based
Practice Center (AHRQ 2001), and the NQF project Steering
Committee. “The transmission of care information in a
timely and clearly understandable form to patient’s current
healthcare providers who need that information to provide
care” ranks in the top-10 of this NQF-endorsed set of safe
practices (NQF, p. vii).
As accreditation and regulatory groups began targeting
communication as a quality-of-care indicator, inadequate
information transfer has expanded from an individual
administrative problem to a public health policy issue
(Joint Commission 2005). The Joint Commission has published
guidelines that specifically address recommendations
for nursing shift handoffs (Joint Commission 2005).
In its 2006 National Patient Safety Goals, the commission
requires hospitals in the U.S. to “Implement a standardized
approach to hand-off communications, including
an opportunity to ask and respond to questions.” (Joint
Commission 2005). However, integrating these guidelines
along with the findings of empirical, theoretical, and clinical
evidence into standards of care, and then translating
these into the day-to-day caregiving activities of frontline
clinicians has posed a significant challenge.
For nursing, patient safety and quality is directly
linked to correct and complete information received at
the change-of-shift interchange. Nurses’ use shift report
information in assessing patient needs, planning patient
care, establishing goals, and prioritizing and managing
their care. Hospitals in the U.S. recognize and benchmark,
(through participation in performance improvement
surveys provided by such organizations as Press-Ganey)
the toll of missing or incorrect communication of patient
information resulting in omission of patient care
and dissatisfaction from patients, families, and clinicians
(Press-Ganey 2002). For example, Press-Ganey Survey
data revealed an opportunity for improvement in scores on
variables related to patient confidence in care, their feeling
safe and secure, being kept informed, being included in
the decision-making process of patient goals, and perceiving
how well the staff work together to care for them. In
addition, nurse satisfaction related to nurse-to-nurse interaction,
teamwork among nurses, and having adequate time
for patient care was also benchmarked against the National
Database of Nursing Quality Indicators (2006).
The literature suggesting that clinicians do not apply
what is known about best handoff practices is copious
(Lamond 2000; Payne et al. 2000; Sexton et al. 2004). A
major barrier to using the evidence of current research
for attaining best handoff practice is clinician and patient
attitudes and lack of knowledge (Manias & Street 2000;
Sexton et al. 2004). Numerous studies indicate that handoffs
are often lacking in depth (Lamond 2000; Sexton et al.
2004). Nursing school curricula on handoffs is only fairly
adequate, and varies widely based on current practices in
clinical agencies in which students receive their clinical experience.
Other barriers include system problems (Hardy
et al. 2000), and lack of standards, policies, and protocols
that integrate research innovations into practice (Sherlock
1995; Joint Commission 2005).
Although significant advances in information technology
and millions of research dollars have given nurses
the tools to obtain significant data at the start of their
shift to be able to prioritize patient care and manage
their patient load effectively, the transfer of information
in a clear, timely manner that puts the patient central to
all information surrounding caregiving activities remains
inadequate. Traditional methods of shift report such as
verbal, taped, and “silent report” tend to be long, inconsistent,
and are fraught with missing or incorrect patient
information (Manias & Street 2000; Anderson &
Mangino 2006). Frequently the content reverts to irrelevant
statements or judgmental comments, leading to negative
attitudes by the oncoming nurse (Elm 2004). Poor
communication between clinicians may prolong recovery,
impede rehabilitation, or precipitate complications
especially dangerous to vulnerable hospitalized patients
who have predisposing comorbidities. Missing or incorrect
communication of patient information can result in
omissions of relevant patient care, and dissatisfaction from
patients, families, and nursing colleagues (Manias&Street
The gap between what we know (research) and what we
do (practice) is at the heart of the research translation
60 Second Quarter 2010 Worldviews on Evidence-Based Nursing
Protocol for Nurse-to-Nurse Handoffs
problem in implementing a standardized approach to
handoff communications. Unfortunately, it can take 10
years for research-based approaches to become integrated
into standards for care (Coyle & Sokop 1990; Barta 1996;
Estabrook et al. 2003; French 2005). This requires an
innovative method to remove the barriers to effectively
translating these discoveries in a cost-effective manner in
order to change clinician practice in an entire organization,
improve patient outcomes, and integrate these innovations
into the education of future (student) clinicians.
Studies in research utilization and translation suggest that
organizations in which nurses practice and students learn
can either foster or inhibit the application and translation
of new knowledge into practice (Horsley et al. 1983; Titler
et al. 1994; Dufault et al. 1995; Rogers 1995; Stetler
et al. 1998a; Dufault 2001). It was believed that student
involvement in the project would facilitate future incorporation
of best practices on nurse-to-nurse handoffs into
patient care and provides students, as well as clinicians,
with an experiential opportunity to learn the process of
translating research findings to solve day-to-day clinical
The goal of this project was to use a six-step translatingresearch-
into-practice approach, the Collaborative Research
Utilization (CRU) model, to develop and test an
evidence-based, patient-centered, best practice protocol
for nurse-to-nurse shift handoffs in a 129-bed, magnetdesignated
urban community hospital. The hospital serves
a high population of tourists, the military and older adults
from the surrounding community that is similar in the
percent minorities, gender, and socioeconomic status to
other community hospitals in the state. With its full range
of services, including inpatient and ambulatory surgery,
acute inpatient care, emergency services, obstetrical, pediatric,
inpatient behavioral health services, intensive care,
inpatient and outpatient rehabilitation services, it also has
a wide range of community health education and prevention
programs. The hospital has had a highly integrated
computerized patient information and nursing documentation
system for several years. Patient acuity is typical for
a community hospital with nursing care hours per patient
day on the medical-surgical units that compares favorably
with that of other similar size and type hospitals, at 7.4
hours per patient day. In 2004, the hospital was awarded
magnet designation by the American Nurses Credentialing
Center. Contractual agreements with the state university’s
College of Nursing as a clinical site for graduate and undergraduate
students are in place.
In the first three steps of implementing this model, a
team of nurses and undergraduate and graduate nursing
students generated the evidence-based, patient-centered,
“best practice” protocol.
The overall project’s framework comes from theory in research
utilization as well as Roger’s “adoption of innovations”
theory. In addition, Orlando’s (1990) middle-range
theory provided the theoretical evidence for the specific
patient-centered, best practice protocol, and is discussed
further under Step 2 of the approach.
Adoption of Innovations Theory
The adoption of innovations theory focuses on understanding
how behavioral change is brought about in an
organizational system. According to the theory, three factors
improve research translation into practice: the availability
of a body of validated, predictable knowledge, a
cadre of clinicians competent in translating and using this
knowledge with favorable attitudes toward research, and
a supportive policy-generating structure that promotes innovation
(Titler et al. 1994; Dufault et al. 1995; Rogers
1995; Janken & Dufault 2002). Use of the CRU model,
based on Roger’s theory, addresses each of these factors.
First, the model provides for resources to review the body
of validated literature on nursing shift handoffs. Second,
faculty-led, experiential, problem-focused learning exercises
called research roundtables guide clinicians and students
to evaluate and translate this empirical knowledge.
Third, themodel provides for the organizational structures
within the hospital to create, test, and sustain the evidencebased
policies, standards, and processes needed to cue
clinician action. In the CRU model, a six-step approach
is used as adapted from the Conduct and Utilization of Research
in Nursing Project (Horsley et al. 1978). The steps
also correspond to Roger’s five-stage process of agenda
setting, matching, redefining/restructuring, clarifying, and
routinizing in the process of describing the adoption of new
practices within organizations. The sequentially designed
activities progress from step 1 to step 6 and are described
in detail in the context of Roger’s theory in Janken and
Dufault (2002).
In the model, nurse researchers are paired in teams
with clinicians, clinical specialists, and undergraduate and
graduate nursing students to address the specific clinical
issue, in this case, the development of a patient-centered,
best practice protocol for nurses’ shift handoffs based on
empirical, theoretical, and contextual evidence to support
its use.
Over 20 years of experience with using the CRU model
has provided insight into this strategy that helps translate
successful research-based interventions into clinician
Worldviews on Evidence-Based Nursing Second Quarter 2010 61
Protocol for Nurse-to-Nurse Handoffs
practice. Using this model to change clinician practice and
sustain organizational change had previously been applied
to other clinical problems and empirically tested in seven
other studies in which the evidence-base is strong, but underused
in practice (Tracy et al. 1995; Dufault & Lessne-
Willey 1999; Dufault & Sullivan 1999; Dufault 2004; Dufault
et al. 2006). Between 1985 and 2005, as the first step
in themodel, over 70 research roundtableswere conducted
to change nursing practice in 26 target clinical content areas
where practice lagged behind a large body of empirical
knowledge (Tracy et al. 2006). Since 2005, an additional
25 roundtables have been conducted in areas related to systems,
processes, and the environment of care. It had never
been used to design and test a standardized, evidencebased,
patient-centered approach to handoff communications
for present and future clinicians. An advantage of
using the CRU model to formulate best practice standards,
policies, and protocols is that it may improve the clinical
environment by translating research-driven change in
practice, as well as to develop present and future clinicians
who are competent in these skills.
The six steps of the approach are:
1. Identification of the clinical problem and assessment
of the empirical, clinical, and theoretical evidence for
potential translation.
2. Evaluation of the relevance of the empirical evidence
as it relates to the selected problem, agency values,
standards and policies, and potential cost and benefits.
3. Designing a policy, standard of care, or protocol that
meets the needs of problem.
4. Actual or construct replication and evaluation of the
policy, standard of care, or protocol.
5. Decision to adopt, alter, or reject the policy, standard
of care, or protocol.
6. Development of means to sustain, disseminate, and
extend the innovation to other settings.
Step 1. Identification of a clinical problem and assessment
of the clinical, theoretical, and empirical evidence for potential
translation. Improving the clinical environment by translating
research on nurse-nurse handoffs into practice at the
bedside was recognized as a need in the hospital.
Assessment of Clinical Evidence
Prior to this project, nurses identified that the method
of shift-to-shift handoffs at the study site was inconsistent
with no hospital-wide standard format for nurse-nurse
handoffs. This posed a particular problem for those nurses
who float from unit to unit and were expected to use whatever
format was operational on each unit of the hospital.
With nurses questioning the feasibility and usefulness of
various methods, there was also no data on the timeliness
or cost related to overtime for the multiple methods of shift
report at the study site.
The types of formats used at the hospital included verbal
reporting, audio-taped in combination with verbal, and
in others, a rounding format. On one unit, a new hybrid
method had been initiated which was a semi-silent report
format based upon computer-generated documentation. A
nurse-satisfaction survey was conducted by a staff nurse
on this unit before and 6 months after the change to semisilent
report. Survey findings suggested that the silent,
computer-generated report format resulted in a negative
impact on team functioning with 74% of the nurses reporting
worsened overall team functioning. Also, 47% of
nurses reported a negative impact on the student or graduate
nurse experience when the silent computer-generated
report was used on that unit (Taft 2006). In addition to
Taft’s survey hospital scores on related NDNQI measures
were examined. Two nurse-satisfaction outcomes including
satisfaction with nurse-to-nurse interactions, and satisfaction
with teamwork among nursing staff were at a high
level. However participation in decision-making and time
for patient care were in the moderate levels with T-scores
at 51.54 and 51.18 levels as compared with other magnet
hospitals of similar bed-size.
It was also noted that at the study site, Press-Ganey
scores on patient satisfaction with variables believed to
be associated with nurses’, shift handoffs had all declined
slightly over the past year. Patient satisfaction outcome
results for items related to how well the nurses kept patients
informed, how well staff worked together to care
for patients, with staff efforts to include patients in decisions,
staff concerns for privacy, and patient’s perceptions
of safety and security while in the hospital were 87.6; 91.1;
88.0; 89.7; and 91.8, respectively. Each of these scores
represented a slight decline from the previous 3 month
reporting cycle, although they still remained above the national
Assessment of Theoretical Evidence
In addition to the CRU model with its underpinnings
of Roger’s Adoption of Innovations Theory to frame the
overall translational research project, Orlando’s Nursing
Theory was used as theoretical evidence to support
change to a standardized format that recognizes
the immediate needs of patients, and is patient-centered.
Orlando’s theory is congruent with the philosophy of
Nursing at the hospital, which draws from the works
of Henderson (1991), Orlando (1990), and Watson
(1988). Effective communication has been embraced by
Newport Hospital in a “back to basics” approach to
professional nursing practice and is in alignment with
62 Second Quarter 2010 Worldviews on Evidence-Based Nursing
Protocol for Nurse-to-Nurse Handoffs
Orlando’s theory of meeting the immediate needs of patients
and supporting the concept of nursing’s role as a
patient/family advocate.
Orlando’s theory focuses on the deliberative nursing
process (Orlando 1990). As described by Schmieding
(2006), Orlando views the role of the nurse as finding
out and meeting the patient’s immediate need for help.
Nurses use their perception, thoughts about their perception,
or the emotions elicited to explore with patients the
meaning of their behavior. Using this process assists the
nurse in eliciting the nature of the problem and identifying
what help is needed for the patient. According to
Schmieding, “the use of her theory keeps the nurse’s focus
on the patient” (Schmieding 1986, p. 1), thus making it
especially suitable for application to the process of nursing
handoffs.When applying Orlando’s theory, the nurse identifies
her own perceptions, thoughts, and feelings about the
patient’s behaviors as she obtains them from the computerized
rounds report and the nurse reporting off in the
situation, background, assessment, and response (SBAR)
portion of the process. She then validates them with the
patient during the bedside component of the shift handoff.
Deliberative nursing actions to meet immediate patient
needs for the next 8 hours are the next step. Last, she verifies
with the patient whether or not she met his needs, and
determines if further action is needed when she prepares
her summary as the off-going nurse at the end of her shift.
Specific examples of the application of Orlando’s theory
to the specific components of the protocol are listed in
Table 1.
Assessment of Empirical Evidence
To assess the body of empirical evidence, literature
searches were conducted from 1992 to 2009 in the Medline
(via Pub-Med), CINAHL, and Cochrane Database of
Systematic Reviews using the search terms of shift report,
handoffs, handovers, end-of-shift report, nurse-tonurse
report, bedside shift report, computerized report,
and silent report. ERIC was also searched in the understanding
that teaching students the technique of shift handoffs
is an important role of nurses, and may have been
reported in the literature. In addition, resources gathered
from a teleconference sponsored by Healthcare Pro (2006)
and Holly (2006) at the 2006 Eastern Nursing Research
Conference helped to identify other potential sources of
evidence. References from previous literature reviews on
this subject were manually searched and it was found that
this search was inclusive. Using specific inclusion criteria
for appraisal, 40 abstracts were screened. Articles were
included that were qualitative and quantitative studies as
well as the gray literature that specifically described processes
and interventions for shift-to-shift report by nurses
that could be replicated. Full text articles of all 40 abstracts
were retrieved for closer screening by a doctoral
nursing student at the university. Only one randomized
study had been published on this topic, and most studies
were descriptive and qualitative in design. Consequently,
no meta-analyses were available on the subject. In addition
to the studies found in the search, one unpublished
meta-synthesis was also found (Holly 2006) as reported at
the 2006 Eastern Nursing Research Society Conference, in
addition to the study conducted by Taft (2006) at the hospital.
The 42 studies were critiqued in depth for methodological
strengths and weaknesses. An evidence summary
table detailing each study’s reference and country of origin,
study objectives, sampling and type, design, and major
findings. In addition, criteria developed by Melnyk and
Fineout-Overhold (2005) to rank the strength of the empirical
evidence were applied to each study. Of the 40 published
studies, nine were chosen for presentation and further
discussion at a research roundtable in Step 2 because
they specifically addressed the process issues identified by
staff nurses in Taft’s (2006) study and in focus groups,
and tested specific methods for shift handoffs. These process
issues included lack of depth, clarity, timeliness, and
organization of reports; inconsistency and missing or incorrect
patient information; interruptions and social conversation;
and inadequate opportunity for nurse-to-nurse
discussion to facilitate teamwork between shifts. Table 2
presents an evidence summary of the studies chosen for
the roundtable. This concluded Step 1 of the CRU model.
Step 2. Evaluating the relevance of the research as it relates
to the selected problem, agency values, standards and potential
cost and benefits. Critiques of the research evidence
were used in a hospital-wide research roundtable discussions
sponsored and led by staff nurses on two units (surgical
unit and the rehabilitative care unit). Stetler et al.’s
(1998a) tools for utilization-focused reviews were used to
guide the roundtable discussions. During the roundtables,
nine of the studies critiqued in Step 1 were evaluated further
for their clinical applicability, usefulness, congruency
of the study with the theoretical basis for current practice at
the hospital, and substantiating evidence from other studies,
systematic reviews, and potential for translation into a
patient-centered, “best practice” protocol. An earlier version
of these tools has been demonstrated to be effective in
getting clinicians to examine and change their practice in
the seven previous studies (Janken et al. 1988; Dufault et al.
1995; Dufault & Lessne-Willey 1999; Dufault & Sullivan
1999; Dufault 2004; Tracy et al. 2006). Recommendations
were generated and are discussed below.
Worldviews on Evidence-Based Nursing Second Quarter 2010 63
Protocol for Nurse-to-Nurse Handoffs
SBARP best practice protocol for nursing shift handoffs, with supporting empirical and theoretical evidence
1. A standardized SBARP format is to be used
as follows:
Experienced nurses have a clear idea of a “good”
handover—it is rapid, goal-directed, effective, brief
(Payne et al. 2000; Dowding 2001), and
patient-centered (Malestic 2003; Anderson & Mangino
A systematic structure of the report organizes large
amounts of data in a meaningful way to convey
complex patient care issues.
There are essentially four practices that are basic to
nursing: (1) observation, (2) reporting, (3) recording,
and (4) actions carried out with or for the patient
(Orlando 1990, p. 31).
The oncoming nurse will:
Review assignment sheet.
Obtain required online documentation on
all assigned patients.
Read the information on the computerized
rounds report.
Meet with the off-going nurse and review
information adding info not on the rounds
Each off-going nurse will provide a verbal
report on each patient using the SBARP
format emphasizing “forceful feature” to
highlight critical areas in the following
There is need for clarification in each health care
institution of the purpose of change of shift report as
well as the roles of the reporter and the receiver (Clair
& Trussell 1969; Parker 1996).
Computer-generated shift reports reduce noise and
chaos (Miller 1998; Baldwin & McGinnis 1994), and are
inclusive of information needed.
Handovers function to produce group cohesiveness
(Payne et al. 2000).
Preprinted handover sheet more effective (Reilley &
Stengrevics 1989; Miller 1998).
Handovers are more effective when they are thorough,
concise, and patient centered (Hardy et al. 2000;
Malestic 2003; Simpson 2005).
Face-to-face interaction in the handoff is salient (Mason
2004; Patterson 2005), and promotes the
professionalism of nursing and team cohesion (Lally
1998; Kerr 2002).
A nurse’s observations are the raw material with which
she makes and implements her plans for the patient’s
care. Observations that are indirect include hearing
comments about the patient at reports. . .or through
perusal of the doctor’s order sheet, progress notes,
nurse’s notes, etc. (Orlando 1990, p. 7).
An unencumbered working relationship between nurses
is vital for the provision of professional nursing
(Schmieding 1986, p. 28).
Review patient’s admitting information,
diagnosis and problem list.
Using computerized rounds report, review in
this order:
past medical history
resuscitation status, patient social
current orders,
scan med/IV list.
Specific order of shift report was noted that aids an
individual’s search for patterns (Lamond 2000).
Communication problems are the no. 1 cause of sentinel
Five recommendations:
1. Use clear language.
2. Incorporate effective communication techniques.
3. Standardize shift to shift and unit to unit reporting.
4. Smooth handoffs between settings.
5. Use technology to your advantage.
(Joint Commission 2005).
Indirect knowledge of the patient consists of any
information that is derived from a source other than
the patient (Orlando 1990, p. 32).
64 Second Quarter 2010 Worldviews on Evidence-Based Nursing
Protocol for Nurse-to-Nurse Handoffs
Oncoming nurse will:
Verify the most recent patient
assessment with off-going nurse.
View lab results.
View most recent vital signs and note trend.
Read progress notes online.
Choose one technique of report and stay with it (Joint
Commission 2005).
The nursing process begins with a patient behavior. This
behavior results in a reaction from the nurse. The
nurse then confirms her perception, thought, or
feeling with the patient. (Orlando 1972).
The natural consequence of observation is a decision
to act or not to act in relation to what is observed
(Orlando 1990, p. 7).
Off-going nurse and oncoming nurse will
What needs to be done for the next shift?
What is the plan for this patient to move to
next level of care?
1. Purpose—why is the patient here?
2. Picture—what results are we looking for both long
term and short term?
3. Plan—what did or did not work?
4. Part—what part can you play during the next shift?
(Dowding 2001)
Using a framework that contains words that are easily
understood would facilitate communication among
the different professionals caring for the patient
(Schmieding 1993, p. 465).
The purpose of nursing is to supply help a patient
requires in order for his needs to be met. The nurse
achieves her purpose by initiating a process that
ascertains the patient’s immediate need and helps to
meet the need directly or indirectly (Orlando 1990,
p. 9).
Off-going and oncoming nurses will meet
with the patient and signal change of shift.
Introduction of oncoming nurse.
Assess patient concerns?
Discuss plan for the next shift to move
patient toward discharge or to the next
level of care.
Off-going nurse turns over patient to
oncoming nurse.
Staff and student education considerations
Patients want to be heard. They should be given
opportunity to be involved in the handover.
Interpersonal competence during handovers was low
(Cahill 1998; Kelly 2005).
Reporting in front of the patient reassures the patient
that everyone knows what is going on and that the
patient is the priority, provides reassurance, security
(Anderson & Mangino 2006).
By involving the patients in their plan of care and
keeping all caregivers updated on that plan, patients
feel more secure, and are more likely to participate in
their own care and follow recommended health care
options. (Kassean & Jagoo 2005; Anderson & Mangino
In order to change handover practices, nurses from the
units must be actively enlisted for trial and training
(Kihlgren et al. 1992; Baldwin & McGinnis 1994; Parker
1996; McKenna & Walsh 1997; Simpson 2005).
The phenomenon of the nurse-patient encounter
represents a major source of nursing knowledge
(Schmieding 1993 p. 16).
Both the patient and the nurse must participate in a
communication process to identify the nature of the
problem as well as its solution (Schmieding 1986,
p. 5).
When using Orlando’s theory, the nurse identifies her
own perceptions thoughts and feelings about the
patient’s behaviors, then validates them with the
patient (Potter & Tinker 2000, p. 41).
The nurse does not assume that any aspect of her
reaction to the patient is correct, helpful or
appropriate until she checks the validity of it in
exploration with the patient (Orlando 1990, p. 57).
Any observation shared and explored with the patient is
immediately useful in ascertaining and meeting his
need or finding out that he is not in need at that time
(Orlando 1990 p. 36).
Training in the nursing process discipline is viewed as a
prerequisite for teaching the process discipline.
(Orlando 1972, p. 37).
Worldviews on Evidence-Based Nursing Second Quarter 2010 65
Protocol for Nurse-to-Nurse Handoffs
Evidence summary table of studies selected for research roundtable on nurses’ shift handoffs
Anderson, C., & Mangino,
R. (2006). USA
To evaluate
implementation of a
bedside shift report
format on patient staff
nurse, and physician
Thirty-two bed general
surgical unit of a 600
bed tertiary care
hospital in a large
metropolitan area in the
southwestern United
time-series pretestposttest-
A defined methodological
process for
implementation was
utilized including staff
education, feedback
and ongoing evaluation.
Outcomes included:
1. Financial savings.
2. Increased patient
3. Increased staff
4. Increased physician
5. Nurse reports of ease
in prioritizing shift
Lev. III
Cahill, J. (1998). UK To examine patient
perceptions on a
bedside handoff method
Tape recorded interviews
with 10 hospitalized
patients were
conducted one day
prior to discharge.
Grounded theory
Three themes emerged:
1. Maintaining a
professional distance.
2. Establishing
professional sharing.
3. Maintaining patient
Most, not all patients
want to be heard. They
should be given the
option to be involved in
the handover.
Lev. VI
66 Second Quarter 2010 Worldviews on Evidence-Based Nursing
Protocol for Nurse-to-Nurse Handoffs
Dowding, D. (2001).
To examine the effects
that (1) type of
change-of-shift report
(retrospective vs.
prospective) and (2)
(consistent vs.
information has on the
amount of information
documented, recalled,
and used in care
Forty-eight RNs from
acute medical and
acute surgical hospital
wards randomly
allocated to 1 of 4
experimental conditions
study/Factorial design
Type of report had a
significant effect on
care planning ability.
Type of schema had an
effect on accuracy of
documentation and
recall, but not on care
planning ability.
Note: study conditions
were as of an audiotape
without interaction and
opportunity for
Level II
Lally, S. (1998). UK To investigate the
functions of nurses’
communications at the
intershift handover
Six handovers on a
surgical/vascular unit in
a UK hospital.
Ethnography The intershift report
involves messages and
strategies that
enhanced social
cohesion of the team as
well as the medium for
transfer of patient
Level VI
Worldviews on Evidence-Based Nursing Second Quarter 2010 67
Protocol for Nurse-to-Nurse Handoffs
Lamond, D. (2000). UK To compare the
information content of
the nurse
change-of-shift report
with documented notes
Study also explores
information in the shift
report forceful feature
(a situation that allows
an individual to access
appropriate knowledge
within their long-term
memory store).
Medical notes, nursing
documentation, and
shift reports for 60
patients in two acute
medical and two acute
surgical wards in
southeast UK.
Two-by-two comparison
Patient notes/charts
contained more
information than given
at change of shift—with
the exception of global
judgments of the
patient’s psychological
information. This
information is often
communicated orally
instead of written.
Correlation between
information in
documentation and
report was r = 0.47 (p <
Forceful features were
identified in the report
as being:
1. Specific order of shift
report was noted that
aids an individual’s
search for patterns.
2. Global information
given in report, along
with organized
information facilitates
information processing
by the
recipient of report.
Level VI
68 Second Quarter 2010 Worldviews on Evidence-Based Nursing
Protocol for Nurse-to-Nurse Handoffs
Parker, J. (1996). Australia To observe the content
process, and methods
of handovers
Twelve handovers in
critical care, burn, step
down, medical, and
surgical units of two
major teaching
Ethnography A variety of processes
were used, use of
notes, computer
printouts, no notes.
Emerging patterns
1. Clinical transmission
of information
2. Management of unit
3. Peer review of
4. Debriefing of anxiety
provoking events
Lev. VI
Patterson, et al. (2004).
To describe the strategies
used during handoffs in
four settings with high
consequence for
Observational hours:
Nuclear Power-177
Railroad dispatch-60
Ethnographic Qualitative
Analysis of
observational data
All handoffs were
interactive and
face-to-face with 19
strategies identified.
Lev. VI
Payne, S., et al. (2000). UK To explore how nursing
records are used in the
process of exchanging
information about
geriatric patient care
146 observation hours of
23 handovers and 34
interviews of nurses in
addition to written
records, care plans,
and “scraps” in 5
geriatric hospital units.
Ethnographic qualitative Experienced nurses have
a clear idea of a “good”
handover—it is rapid,
goal-directed and brief
(this presents problems
for new staff or SNs).
Handovers function to
produce group
Frequent use of jargon
and abbreviations.
Production of Kardexes
and care plans appears
to be motivated by
concerns of litigation.
“Scraps” important.
Level VI
Worldviews on Evidence-Based Nursing Second Quarter 2010 69
Protocol for Nurse-to-Nurse Handoffs
Sexton, A., et al. (2004).
Comparison study of the
content of nursing
handovers to formal
documentation sources
Thirty bed general surgical
ward in suburbs of
Sydney, Australia.
Twenty-three nursing
handovers covering all
shifts were audio-taped
and observed by two
Mixed method 93.5% of information
passed at handover
was already available in
the medical record or
other written sources.
Some handovers
promoted confusion
Level IV
70 Second Quarter 2010 Worldviews on Evidence-Based Nursing
Protocol for Nurse-to-Nurse Handoffs
Research Roundtable Findings
There are few studies that examine the efficiency, costeffectiveness,
and clinical outcomes of specific approaches
to nursing shift handoffs. Dowding (2001) found that the
type of report had a significant effect on an individual’s
ability to plan patient care and the type of information
content on their ability to accurately record and recall
the information they heard. Subjects can recall more information
accurately when they hear prospective reports
and schema-consistent patient information. Patterson
et al. (2004) found that effectiveness and efficiency improved
when handoffs were provided in the same order
every time, were verbal, face-to-face, where there were
limited distractions and interruptions, and provided a summary,
plan and goals. The findings of Dowding and Patterson
were substantiated by staff nurses in their discussion
of the studies. They noted that they too were able to recall
and use the information given in report when there was a
predictable pattern to the delivery of information. Nurses
further indicated interest in a new format they learned in a
Healthcare Pro (2006) conference as developed by Kaiser
Permanente of Colorado (2006), called the SBAR (situation,
background, assessment, and response) method to
enhance communication during handoffs, although it had
not been empirically tested at the time of this review.
Considerable discussion during the roundtable focused
on the “silent report” method having received more attention
recently as a cost-saving method where minimal communication
between nurses eliminates “time-over shift”
or excess overlapping of oncoming and leaving shifts of
nurses. As early as 1994, using a computer-generated nursing
written shift report, Baldwin & McGinnis (1994) reported
outcomes of this type including reduced overtime,
increased direct patient care at the shift change, and improved
communication of pertinent patient data. Reduced
legal risk of breech of patient confidentiality due to overheard
conversations, decreased admission wait time, and
reduced noise and chaos also resulted. Roundtable participants
challenged Sexton et al. (2004) study that questions
whether nurses need the handoff verbal report. Sexton
found that 93.5% of information passed at the handoff was
already available in the medical record or other written
sources. However, participants were in agreement with Lamond’s
(2000) study suggesting that there is evidence that
the verbal handoff contains “forceful feature” information
that may facilitate the processing of patient information
that leads to more efficient care planning. A study by Taft
(2006) at this study site found that the silent computergenerated
report format resulted in a negative impact on
team functioning with 74% of the nurses reporting a worsened
overall team functioning. This is also consistent with
Lally’s (1998) finding that the verbal intershift handoff enhances
a shared value system amongst nurses. In Taft’s
study at the hospital, 47% of nurses reported a negative
impact on the student or graduate nurse experience when
the silent computer-generated report was used (Taft 2006).
Most recently, bedside nurse shift reporting in which
patients are included in the handoff process has been
attempted to have patients more involved in their care.
Kassean and Jagoo (2005) found this method facilitated
nurses obtaining salient data and their ability to prioritize
and manage patient care effectively. Anderson and
Mangino (2006) also found that bedside reporting resulted
in a decrease in time-over shift (incidental time),
took less time, and assisted nurses in prioritizing their
work because they were able to visualize all patients within
the first half hour of their shift. Staff nurses reported increased
satisfaction related to accountability, interpersonal
relationships, and receiving pertinent information. Physician
satisfaction improved with their reporting more informed
nurses. Key patient satisfaction improvementswere
achieved in the areas of nurses keeping patients informed,
how well the staff worked together to care for patients,
and the patient perception of inclusion in the decisionmaking
process, including decisions about their treatment
(Anderson & Mangino 2006). However, adding the element
of a bedside component that includes the patient
and ancillary staff has only been empirically evaluated in
these two studies, and nurses who reviewed Anderson and
Mangino’s study pointed out that it was a nonrandomized
time-series pretest-posttest-posttest designed study, rather
than a randomized, controlled trial. Despite this, nurses
from the intensive care unit who include a bedside component
strongly advocated including the patient in the report.
They further pointed out that there is strong theoretical
evidence from Orlando’s work, on which the theoretical
framework for the nursing department is based, to support
including a bedside component in the protocol to be
A consistent approach to information transfer with
guaranteed patient-nurse contact was becoming an important
aspect of the patient-centered, best practice protocol
to be developed. A staff nurse conducting a related study
on the impact of nurse’s intentional presence pointed out
that studies suggested that increasing contact with nurses
has been identified as an important variable in improving
patient outcomes (Fordham & Dunn 1994). They found
that a powerful function of a nurse is the ability to promote
trust with patients. The nurse also pointed out that consistent
behavior and freedom from uncertainty and doubt
were found to be influential trust factors in a study by
Meize-Gochowski (1984).
Roundtable participants also identified Joint Commission
recommendations that need to be consulted specify
Worldviews on Evidence-Based Nursing Second Quarter 2010 71
Protocol for Nurse-to-Nurse Handoffs
Recommendations and supporting empirical evidence generated in research roundtable discussions
1. Need goal-focused, thorough, rapid and brief report (Payne et al 2000)
2. Active verbal communication—person to person needed to allow mentoring and team building (Payne et al. 2000; Dowding
2001; Patterson 2005, Taft 2006)
3. Consistent, organized format needed (Lamond 2000, Dowding 2001)
4. SBAR (situation, background, assessment, and response) (Kaiser Permanente of Colorado 2006) format with integration of
patient (add “P”)
5. Need to have status of all patients on unit (Taft 2006)
6. Patients need to be included with walking rounds at bedside (Cahill 1998; Anderson & Mangino 2006)
7. Joint Commission Recommendations: clear language, standardized shift to shift and unit to unit report, effective communication
techniques, use technology as adjunct (Joint Commission 2005).
8. Need training on handovers (Parker 1996)
that clear language, a standardized approach, and use of
effective communication techniques with technology as
adjunct seemed in concert with all of the empirical evidence
presented during the roundtable. Finally, it was
noted that there needs to be time protected to train all
staff, as well as students, in the protocol to be developed. In
summary, eight recommendations specific to the patientcentered,
best-practice protocol were generated (listed in
Table 3).
Step 3. Designing evidence-based best practice standards,
policies, or protocols for translating recommendations generated
in the research roundtables to conform to the organization’s
specific needs. A subgroup of the hospital’s Nursing
Research Committee representing staff nurses from each
of the hospital units worked with the research consultant
and a doctoral student to discuss the eight roundtable
recommendations for congruence with findings of the 34
studies not presented in the research roundtable. In addition,
they conducted further interviews with staff nurses
on each of the units to establish the exact process currently
in use for handoffs and for use of the computergenerated
rounds report evaluated in Taft’s (2006) survey.
A best practice for nursing shift handoffs was generated,
using the evidence of the 42 empirical studies,
Orlando’s theory, contextual factors such as existing policies
and values, nursing staff competency and patient preferences
as described in the Press Ganey Patient Satisfaction
Survey data. Table 1 describes the patient-centered,
evidence-based, best practice protocol developed for the
Standardization and stabilization of clinical practice related
to the transfer of information is an essential aspect of
patient safety and improves clinical outcomes. In this article,
the first 3 steps of the CRU model as used to develop
the patient-centered, best practice protocol were described.
Incorporating directions established by AHRQ, the Joint
Commission and the NQF this project created meaningful
clinician change in the hospital setting to a standardized,
evidence-based, patient-centered approach to nurses’
change-of-shift handoffs.
Using the CRU model, an innovative empirically tested
method of translating research into practice, may ensure
that results are disseminated both in the clinical and academic
community. This is consistent with Dopson &
Fitzgerald (2005) integrating framework to understand
how clinicians and organizations use empirical knowledge
for decision-making. It is clear that in the CRU model, a
critical role is played by key individuals or “research champions”
at the staff nurse and management levels in partnership
with academic affiliates to promote an evidencebased
health care culture. This also supports the findings
of Gabbay and Le May (2004) whose ethnographic study
of knowledge management through the collectively constructed
“mindlines” identified the role of providing networking
opportunities and the significant implications this
has for translating research findings into communities of
practice. Participation in activities of the CRU model, such
as research roundtables and focus groups, provide such
networks for students, clinicians, administrators, and scientists
to ensure that research is practice-based and practice
is research-based. The potential for future nurses to use
this method through their involvement in the project can
have a positive and sustained long-term impact not only
on amore effective approach to handoffs, but to other clinical
problem-solving in their future. The decision to sustain
the protocol, and to disseminate and extend testing
the protocol for feasibility, usefulness, and effectiveness
in improving clinical and fiscal outcomes in other hospitals
(Steps 3, 4, and 5 of the CRU model) is currently in
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