1. Daniel, Laura PhD
  2. N-Wilfong, Donamarie DNP, RN

Article Content

The importance of handoff reports is well documented to help seamlessly transition coordinated patient/family-centered care between nurses changing shifts. The quality of communication used in these reports plays a crucial role in their effectiveness. In fact, ineffective communication is the leading cause of sentinel events in the United States.1 As such, institutions have implemented strategies and policies to ensure these interprofessional exchanges are effective, timely, and standardized, following a Situation, Background, Assessment, Recommendation (SBAR) format (or using detailed checklists).


Shift reports were moved at Allegheny Health Network from nurses' stations to the patients' bedsides in an effort to provide more patient/family-centered care. This policy change was created in hopes to ensure effective communication between nurses and to establish a partnership between the nurses and their patients/family members.


An internal, online, hybrid simulation course on effective handoffs was also created to ensure effective reports. All nurses from the network were then asked to view a voice-over presentation specifically on bedside reporting following the course. These educational interventions were practical approaches to ensure nurses were taught the proper information and skills required for competence. Next, nurse educators began to audit the bedside reports and collect data to evaluate their thoroughness. This article describes the online course and subsequent video, explains the methodology and justification of the bedside audits, and presents a few findings that were revealed as a result of the audits.


Educational interventions

The online handoff course was designed to improve staff members' communication knowledge and skills. The course began with a 15-item pretest containing both multiple choice and true/false questions to gauge baseline communication skills. Participants then progressed through a presentation on proper communication techniques based on the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS(TM)) program, which was developed by the Department of Defense's Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality (AHRQ).2 TeamSTEPPS is an evidence-based teamwork system for healthcare organizations to increase patient safety by enhancing the cohesion of interprofessional teams.2


Following the self-paced slide presentation, the participants then watched five high-fidelity patient-safety simulations originally performed during an internal handoff communication conference. These vignettes were designed by a multidisciplinary team of professionals who had completed the AHRQ's TeamSTEPPS Master Trainer program. These experts directed the production of the scenarios to ensure they showcased concepts of: situational awareness; situation monitoring; the SBAR communication tool; the shared mental model; and the importance of integrating elements (such as call-out and check-back) accurately (see AHRQ definitions).3 Each of these vignettes modeled the same scenario twice: once displaying excellent communication exchanges and once with poor communication exchanges.


The poor communication vignette was shown to emphasize the far-reaching and often dire consequences that may result from poor interprofessional exchanges. It also displayed the intense emotions the provider and patient may experience after an error has occurred. These simulations were performed in a handful of clinical settings (prehospital/ED, obstetrics, medical/surgical, and the OR) to appeal to learners from multiple specialties while reflecting real-life practices. Participants were required to receive an 80% passing score on the posttest. Upon successful completion of the course, participants were expected to be knowledgeable on the proper techniques that can be used to enhance communication between professional team members.4


Educational video

Nurses were asked to watch a 25-minute educational video following the handoff course. This voice-over video extended the information from the handoff course by specifically relating the handoff communication to bedside reports. The video was intended to teach nurses the rationale for bedside reports, ways in which bedside reports can enhance the patient experience, and evidence-based strategies for implementing bedside reports. Increased support for bedside reports and increased motivation among nurses were additional expected outcomes of this video.


This video also detailed simulations with standardized patients. These videos gave nurses an idea of what to expect when patients and/or family members are involved in the process and how they may change report dynamics. For example, the speed and the terminology used during the bedside reports may need to change when speaking to patients and their family members. Updating communication boards in each patient room, with nurse/patient and family partnering, was also addressed. Communication boards are designed to introduce the patient's care team, define daily patient-care goals, and provide an opportunity to answer any questions.


Bedside audits

While healthcare providers may learn communication skills and handoff techniques from this course, it is uncertain as to whether or not they will implement them into practice. As such, nurse educators from across the 7-hospital network began observing the nurses' bedside handoff reports for quality evaluation. A psychometrician and a panel of expert nurse educators created a simple checklist to guide nurse educators' observations. This user-friendly checklist consisted of 25 items that need to be implemented to perform a complete handoff, such as "introduces him/herself" and "assesses pain," to which the observing nurse educator checks "yes," "no," or "NA." All of the items on the observation checklist were objective, and thus, interrater reliability was not examined.


Nurse educators observe as many bedside handoff reports as they can in a month and obtain the unit manager's signature on each checklist. The completed checklists are then given to the systemwide director of nursing education who then calculates the percentage of each performed task. A 100% completion is the goal for each of the bedside report aspects. These percentages are tracked over time and across units and hospitals. The audit results are shared on a monthly basis with senior leadership, nurse managers, and frontline staff, providing the institutional leaders with a sense of which aspects of the bedside report the nurses are performing and which they are omitting.


These audits provide educators real-time data on the accuracy and efficiency of current handoff reports. For example, during the most recent month, nurse educators observed 76 units across the 7-hospital network, and there were four aspects of the bedside reports that were identified as areas of needed improvement. "Addressing fall risk," "assessing infusions," "updating communication board," and "completing the report at the bedside" were completed during less than 100% of the observed reports on at least nine units.


Any re-education deemed necessary is provided to nurse(s) via nurse educators to ensure thorough understanding and compliance. If a nurse begins the report in a location other than the patient's bedside, that particular nurse would be asked to complete an online module with the nurse educator monitoring another handoff report in the future. This remedial online module is a video that the systemwide director of nursing education created that describes the best practice standards of bedside shift report, provides an example of how to give the report, and discusses ways to handle privacy issues.


If a nurse omits 1 or more of the 25 items on the bedside checklist, the nurse educator would provide the nurse with "just-in-time" counseling, which means he or she is counseled by the nurse educator, and review the audit tool with the nurse to highlight omitted area(s). The nurse educator will also review best practice with the nurse, discussing the best way to organize their report to ensure that all of the proper information is exchanged. The nurse educator will also observe this nurse completing another handoff report for a second time in the future.


A novel approach

In summary, Allegheny Health Network created a novel way to generate support for and mandate bedside reporting. An online hybrid simulation course provided nurses with the knowledge needed for effective handoff communication, and a subsequent video focused on the specifics of bedside reporting to justify this policy and to inspire nurses to perform it well. The bedside audits that followed provided institutional leaders with data gauging the completeness of the reports. Time restraints cause the number of observations to vary from unit to unit and month to month, which may skew the data. Additional research is needed to assess improvements in outcome measures. Other institutions that wish to implement bedside reporting can follow this educational/observation model.


AHRQ definitions3

Situational awareness - The state of "knowing what is going on around you."


Situation monitoring - The process of continually scanning and assessing a situation to gain and maintain an understanding of what is going on around you.


SBAR - A technique for communicating critical information that requires immediate attention and action regarding a patient's condition.


Shared mental model - Results from each team member maintaining situational awareness and ensures that all team members are "on the same page."


Call-out - A strategy used to communicate important or critical information. Call-out informs all team members simultaneously during emergent situations and helps anticipate next steps. (It is important to direct responsibility to a specific individual responsible for carrying out the task.)


Check-back - Using closed-loop communication to ensure that information conveyed by the sender is understood by the receiver as intended. The steps include the following: Sender initiates the message; receiver accepts the message and provides feedback; sender double-checks to ensure that the message was received.




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2. TeamSTEPPS Home. Agency for Healthcare Research and Quality. [Context Link]


3. Agency for Healthcare Research and Quality: Advancing Excellence in Health Care. Pocket Guide: TeamSTEPPS. [Context Link]


4. Daniel L, N-Wilfong D. Empowering interprofessional teams to perform effective handoffs through online hybrid simulation education. Crit Care Nurs Q. 2014;37(2):225-229. [Context Link]