Examining Nurse Shift Handoffs as a Process within the Flow of Nursing Care

Katherine M Ernst, Purdue University

Abstract

Medical-surgical nurse shift handoffs are cognitively intense, whereby information about four or more patients is exchanged and assimilated to create a consolidated plan of nursing care. A gap in the literature exists, whereby handoffs have been studied not as an activity amidst the ongoing work of the exchanging nurses but as an isolated activity. This exploratory qualitative research investigated the handoff as a process situated within the workflow of outgoing and incoming nurses. Twenty one nurses participated in one of five focus group sessions at two unaffiliated hospitals, discussing their ideal handoff, ways the handoff could go poorly, and effects on subsequent nursing care. The focus groups’ transcripts were analyzed inductively and deductively. Applying a general inductive approach, two major themes were identified: teams/teamwork, and communicating and constructing a shared understanding of the patient’s condition. These themes revealed the ways that the progress of the handoff was impacted as well as the effects post-handoff. Failure Mode and Effects Analysis was utilized as a deductive framework to analyze the focus group content, identifying the generic preferred handoff process, as well as the failure modes, causes and effects of each step in the process. This analysis revealed two notable findings relating the handoff process to effects post-handoff. First, an early failure could facilitate a cascade of negative effects through the handoff process. Second, an effect could have many causal failure modes which appear confounded. Overall, the two analytic methods together revealed the generic ideal handoff process and the importance of the preparatory activities of both nurses in facilitating an efficient and efficacious handoff. Promulgating and adhering to common expectations of the handoff across all members of the handoff team (i.e., the nurse dyad, electronic health record, patient, family and other hospital staff) facilitated better quality handoffs. Poor handoffs were found to take longer and create additional unexpected taskwork for the incoming nurse, which potentially increased nurse workload, resentment between nurses, poor patient-nurse rapport, information gaps and errors in nursing care. New potential measures identified include measuring the window after handoff and before the start of medication administration, capturing the time when nurses perceive they have recovered from a poor handoff (e.g., end of initial charting, lunch, self-care) and utilizing the NASA Task Load Index subjective workload questionnaire. These measures, once validated and correlated with nurse-sensitive patient safety indicators, may prove useful to assess the impact of handoffs on incoming nurses’ patient care.

Degree

M.S.I.E.

Advisors

McComb, Purdue University.

Subject Area

Industrial engineering|Nursing

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