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Including the Patient in Change-of-Shift Handoffs

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By Jennifer Larson, contributor

October 11, 2013 - Good communication among health care professionals is paramount when it comes to delivering excellent patient care, and research has shown that breakdowns in communication can lead to mistakes, and even adverse events.

But how often do providers stop and consider whether the patient’s voice is represented?

In recent years, the patient’s voice has been more and more of a consideration--especially as the movement toward patient-centered care has gained traction and health care organizations have become more concerned with their patient satisfaction scores.

Yet some experts like Mary Ann Friesen, PhD, RN, would like to have the patient’s voice represented in even more aspects of their care. Friesen believes in the value of including the patient--or, in some circumstances, the patient’s family--in the change-of-shift handoff, a transition that traditionally has excluded the patient.

“How can you be patient-centered if you talk around the patient and not with the patient?” said Friesen, the nursing research coordinator for Inova, a not-for-profit healthcare system based in Falls Church, Va. 

Communication’s role in a handoff 

Effective communication is essential when it comes to handoffs.  In fact, patient harm can result from communication failures during handoffs or sign-offs from one provider to another.  Other problems can arise, as well, as noted in a 2012 study for the journal BMJ Quality & Safety that analyzed shift handoffs between nurses and found a great deal of variability. 

John Carroll, PhD, a professor in the Sloan School of Management at the Massachusetts Institute of Technology, described a situation in which a half-dozen nurses who were coming off shift were all crowded into a room with another half-dozen nurses, trying to hand over their patients as quickly as possible. Imagine the noise, he noted. And this scenario assumes that nurses have a dedicated space in which to sign off on their patients, which isn’t always the case. 

Carroll and his fellow researchers also found that experienced nurses tended to shorten their reports when handing off patients, which led to new nurses feeling they needed to ask more questions. That sometimes led nurses to feel frustrated with the communication. 

Carroll said that a disaster won’t automatically follow if something isn’t said during the handoff, but it might make a mistake more likely to occur.

“The hope is that if they communicate better, there will be fewer of those [mistakes],” he said.  

Bringing the patient into the process 

Like the BMJ Quality and Safety study, much of the attention on the communication aspect of handoffs has focused on the nurse-to-nurse angle. So considering the patient’s perspective--and incorporating patients’ voices into the handoff--does require a paradigm shift, Friesen noted. 

In a recent article for the International Journal for Human Caring titled “Caring, Connecting, and Communicating: Reflections on Developing a Patient-Centered Bedside Handoff,” Friesen and her co-authors described the benefits of focusing on better two-way communication with patients during the change of shift.

They wrote that “well-intentioned staff nurses believed they were patient-centered when, indeed, they were not.” They added that the nurses needed “targeted instruction on how to bring the patient into the interaction,” which led to the creation of bedside handoff scripts to help nurses bring the patient to the center of the handoff and truly engage with them.

And that’s how a specific process like the ISHAPED bedside report can be useful. The process was designed to keep the patient at the center of the process, while also respecting patient safety. ISHAPED is an acronym for Introduce, Story, History, Assessment, Plan, Error Prevention and Dialogue.

Nurses can use the ISHAPED form to guide them during the handoff process. For instance, the outgoing nurse and incoming nurse enter the patient’s room together. Then the outgoing nurse introduces the patient to the incoming nurse. The outgoing nurse completes the handoff at the patient’s bedside, rather than out in the hallway or at the nurses’ station. During the transition, the outgoing nurse would communicate back and forth with the patient as he/she goes over plans for the patient. The patient has a chance to ask questions and provide feedback, and both nurses have a chance to participate in the dialogue. During the handoff, the nurse also writes important information on a white board to which a patient could later refer. 

Friesen was also the lead author for a study in the July-September 2013 issue of Journal of Nursing Care Quality that described recommendations for implementing ways to include patients and their family members in the ISHAPED handoff process. 

She credited the Picker Institute, which funded the project detailed in the International Journal for Human Caring, for insisting that patients and family members be involved in the creation of the patient-centered handoff. The patients and family members provided invaluable insight that might not have ever been considered otherwise. 

“That was a true revelation,” she said. 

Another recent study that explored the patient’s role in change-of-shift transitions in the oncology arena noted that patient participation in handoffs is still a new phenomenon that may require some changes. 

“Expanding handoffs to include inpatients would be well supported by most oncology patients, but will require substantial changes in behavior on the part of patients and education,” wrote Nancy Staggers, Marge Benham-Hutchins, Luciana Goncalves, and Laura Langford-Heerman in the article that appeared in the Journal of Participatory Medicine in July 2013. 

They also suggested that “future research might include developing and evaluating specific patient-centered content and processes to support handoffs.”