A systematic review of nurses' inter-shift handoff reports in acute care hospitals

An inter-shift nursing handoff report is the exchange of patient care information for evidence-based nursing and midwifery from one nurse to another, and is a universal procedure used in hospitals to promote continuity of care. The objective of this review was to appraise and synthesize the best available qualitative evidence pertaining to the nursing handoff report at the time of shift change and make recommendations that can enhance the transfer of information between and among nurses, and by extension, improve patient care.

The review considered qualitative studies that drew on the experiences of nurses at the time of inter-shift nursing handoff in acute care hospitals, and included designs such as phenomenology, grounded theory, narrative analysis, action research, ethnographic or cultural studies.

The search strategy sought to find both published and unpublished research papers. An initial search of the Joanna Briggs Institute for Evidence-Based Nursing and Midwifery, the Cochrane Library, and PubMed's Clinical Inquiry/Find Systematic Review database was conducted. Following this, an extensive three stage search was conducted using PubMed, CINAHL, HealthStar, ScienceDirect, Dissertation Abstracts International, DARE, PsycINFO, BioMedCentral, TRIP, Pre-CINAHL, PsycARTICLES, Psychology and Behavioural Sciences Collection, ISI Current Contents, Science.gov, Web of Science/Web of Knowledge, Scirus.com website. Included was a hand search of reference lists of identified papers to capture all pertinent material as well as a search of relevant world wide websites and search engines, such as Google Scholar and the Virginia Henderson Library of Sigma Theta Tau International.

Each paper was assessed independently, by two reviewers for methodological quality prior to inclusion in the review using the critical appraisal instrument QARI (Qualitative Assessment and Review Instrument) developed by the Joanna Briggs Institute for Evidence Based Nursing and Midwifery.

A total of 21 qualitative papers were included in the review of the 42 papers retrieved. Twenty-one were excluded as they did not meet the inclusion criteria. Findings were extracted and a meta-synthesis conducted using JBI-QARI. Three syntheses about the process of handoffs at the time of inter-shift nurses' reports in acute care hospitals were derived: 1) An embedded hierarchy exists that influences the conduct of inter-shift nursing handoffs; 2) Participating in inter-shift nursing handoffs are a way of becoming acculturated into the nursing unit's norms, expectations and rituals; 3) The nurse is the gatekeeper of information handed off that is used for subsequent care decisions.

There is evidence to support that the current process of inter-shift nurses' reports serves several purposes in addition to transfer of information, including the development of group solidarity. It is apparent from this review that the nurse is the gatekeeper for the flow of information regarding patient care and chooses what information to impart and act upon. Multiple ways of transferring information are recommended for the inter-shift nursing handoff as a way to manage information decay or funneling and to address potential communication gaps due to in congruencies between the medical record, verbal handoff report and actual clinical condition.

A consistent guideline is a prerequisite to formulating an optimal shift report given the findings of this review that the quality of information transferred is unpredictable. The guideline needs to take into consideration, not only the exchange of information, but that nurses handle patient information in personal ways. To that end, a one-page report pre-populated with patient demographics, recent vital signs, laboratory results, and other information which can be accessed and printed at point-of-care at the time of change of shift is recommended.

As external agencies continue to call for hand-off standardization that may not, in and of itself, reduce risk, further research is needed to determine the associations between inter-shift nursing reports and patient outcomes. Practice model initiatives, such as SBAR (situation-background-assessment-results) need to be investigated to determine if these methods can prevent information loss, particularly in those areas where information decays quickly, such as the Intensive Care Unit. As well, the current shortage of nurses make the composition of the nursing team less stable with more temporary and part-time workers resulting in a decrease in the cohesiveness and social interaction necessary to becoming acculturated in a nursing unit This could present a barrier to communication of important information and contribute to information loss that needs to be investigated.