Communication Currents

Anyone who has spent time as a hospital patient has seen a nursing communication ritual called the patient handoff. It involves the nurse who is going off shift providing the incoming nurse with critical patient information so she or he is prepared to take over responsibility for patient care. What most people don’t realize is that an estimated 80 percent of serious errors in patient care are in part the result of communication problems during patient handoffs. Our study sought to identify what specific communication behaviors nurses use in effective patient handoffs and determine whether those behaviors differed based on whether the nurse was leaving or reporting for her or his shift.

By understanding what behaviors influence the quality of the patient handoff, nurses can learn how to improve their competency in handoff communication regardless of how an organization standardizes the interaction. Improving the overall communication competence of nurses could lead to improved handoffs and reduced communication-related patient care errors.

Handoff Standardization 

Communication during the patient handoff was deemed so critical to patient safety that in 2006 the healthcare accrediting organization The Joint Commission (TJC) started requiring healthcare organizations to standardize handoff communication. The nurse-to-nurse handoff at shift change is only one type of handoff; others include physician-to-physician, unit-to-unit (e.g., emergency room to critical care), those between allied health professionals (e.g., transporters moving patients), and facility-to-facility (e.g., hospital to nursing home). Since nurses provide the largest share of patient care and the interaction occurs at every nursing change of shift in every healthcare setting, we thought it was important to focus attention on the nursing interaction.

TJC’s handoff standardization requirement launched a frenzy of responses as hospitals and other healthcare organizations sought to find ways to reduce errors in patient care by providing a consistent way of transferring patient information during a handoff. They created standardized formats or checklists to provide an organized, efficient format for capturing important patient information. Computer-based tools were developed, and organizations also looked at changing how the process for the handoff by doing things such as moving it to the patient’s bedside to involve the patient, creating environments with fewer interruptions or distractions, and limiting use of the traditional tape-recorded handoff.  Thus far, none of the standardized handoff practices have proven to be better at reducing patient errors or improving the quality of the handoff. The studies to determine the effect of these changes, however, did not focus on the foundational communication behaviors necessary for a competent handoff. 

Handoffs are complex, and miscommunication may occur because of the lack of a patient safety-focused culture, lack of teamwork and respect among the caregivers, lack of time, inadequate training, ineffective communication methods, and interruptions. Nurses tend to learn about handoff procedures while on the job, with little training as nursing students. Each nurse develops her or his own methods for collecting and relaying patient information to the incoming nurse in addition to using whatever standardized format is required.  

 Communication Competency 

Communication researchers Ralph E. Cooley and Deborah A. Roach in 1984 defined communication competency as “the knowledge of appropriate communication patterns in a given situation and the ability to use the knowledge.” For the medical setting, Donald Cegala identified behaviors associated with the competent medical consult between patients and doctors as information exchange (information giving, seeking, and verifying) and socioemotional communication (fostering warmth, trust, and concern). We believed these same behaviors could apply to the nursing handoff, and the use of these behaviors would differ depending on whether the nurse was leaving or reporting for duty.

Our study involved 286 nurses who completed an online survey through the nursing community website allnurses.com, which now has about 900,000 registered members. Nurses completed a 48-item Medical Communication Competence Scale. To “set the stage,” we randomly assigned them to describe a handoff that was either the best or worst they recalled, in which they were either the incoming or outgoing nurse. On the basis of these descriptions, they ranked their levels of agreement with statements such as:

• “I did a good job of getting answers to my questions.” (Information seeking)
• “The outgoing nurse did a good job of offering recommendations and/or input regarding the patient’s care.” (Information giving)
• “The outgoing nurse did a good job of reviewing important or complex information to make sure I understood correctly.” (Information verifying)
• “I did a good job of showing that I cared about the incoming nurse.” (Socioemotional communication)

Findings Shed Light 

The findings supported our beliefs that in competent handoffs nurses exchanged information by asking and answering questions and verifying patient information to check for understanding. However, we did find that the best handoffs occurred when both the incoming and outgoing nurses shared in giving patient details—two-way information giving—contrary to the traditional practice of the outgoing nurse simply giving information to the incoming nurse—a one-way exchange.

We also found that the incoming nurse, as one would expect, asks more questions—information seeking—than the outgoing nurse. This suggests that incoming nurses who clearly ask specific questions to reduce the chance that critical details are left out have a higher likelihood of getting information needed to improve their ability to take care of patients. Also, the incoming nurse has the greater responsibility for making certain the information provided by the outgoing nurse is correct, complete, and understood—information verifying.

A new finding was that quality handoffs included socioemotional communication behaviors that foster warmth, trust, and concern. The relational aspects were not included in TJC guidelines and have been missing from most of the handoff research. It appears that the incoming nurse has the primary responsibility for setting the tone for the handoff relationship, which would make sense considering that the outgoing nurse is often exhausted after 12 hours of patient care. Relational behaviors include being warm and friendly, using easily understood language, contributing to a trusting relationship, taking steps to make the other nurse feel comfortable and relaxed, being open and honest, and showing compassion. 

Although standardizing patient handoffs has led to the use of organizational tools, formats, location changes, and other modifications, little has been done to identify foundational communication skills that lead to effective handoffs. Understanding key skills can lead to development of teaching tools for nurses (such as a modified version of Cegala’s PACE—Present, Ask, Clarify, and Express—program). By becoming competent in asking, giving, and verifying important patient information while creating an environment that fosters warmth, trust, and concern, nurses can tap those skills as needed for each patient handoff, no matter what standardized process is in place where they work.