Question STEP 1: The members of the group will collaboratively complete the following: 2/2/24
The Clinical Question & Article Search Reference Form (see attached)
•
To complete The Clinical Question & Article Search Reference Form: the
members of the group must work together to:
Identify the clinical question.
Develop the clinical question into PICOT format.
Complete a literature search in relation to the clinical question. (Utilize
the resources in the library: the librarians will be helpful in
completing a literature search for the focused question).
1. Articles must be from a nursing journal.
2. Articles need to be less than 7 years old.
3. Articles need to be a research or evidence-based practice
study.
STEP 2: Submit critique of article (15%)
2/23/24
After reading the article, fill out the Article Critique. (attached)
Upload the Critique and the article to the Assignment area of Brightspace.
3/7/24 & 3/14/24
STEP 3: Group Presentation/Discussion (15%)
Each student will present a 3-5-minute summary of their article and be prepared to discuss
the group topic in a Virtual Conference.
•
Professor Kronenberger will provide information for the conference date and time.
• Provide a one slide per student PowerPoint about your findings./n Received: 5 October 2020 Revised: 17 February 2021 Accepted: 22 February 2021
DOI: 10.1111/nhs.12825
REVIEW ARTICLE
Shift-to-shift nursing handover interventions associated
with improved inpatient outcomes-Falls, pressure injuries
and medication administration errors: An integrative review
Adriana Hada PhD candidate, MN, RN¹ | Fiona Coyer PhD, MScNsg, RN²
¹Division of Medicine, Princess Alexandra
Hospital, Brisbane, Queensland, Australia
2Joint appointment with School of Nursing,
Queensland University of Technology and
Royal Brisbane and Women's Hospital, Metro
North Hospital Health Service, Brisbane,
Queensland, Australia
Correspondence
Adriana Hada, Division of Medicine, Princess
Alexandra Hospital, 199 Ipswich Road,
Woolloongabba, Brisbane, QLD, 4102,
Australia.
Email: adriana.hada@health.qld.gov.au
Nursing & Health Sciences WILEY
Nurs Health Sci. 2021;23:337-351.
Abstract
The aim of this integrative review was to identify which nursing handover interven-
tions were associated with improved patient outcomes, specifically patients' falls,
pressure injuries and medication administration errors, in the hospital setting. The
Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was
used to guide the review. A systematic search of seven electronic databases was con-
ducted, and retrieved articles were assessed by two independent reviewers. The
quality of included studies was assessed using the Mixed Methods Appraisal Tool.
Eight studies met the inclusion criteria. The findings of this review indicate that
improvements in handover communication had a clinically important positive effect
on patient outcomes. Across the studies, reductions in falls varied from 9.3 to 80%,
pressure injuries from 45 to 75%, and medication errors from 11.1 to greater than
50%. This review highlights that the implementation of bedside nursing handover
and the adoption of standardized handover tools to improve nursing handover com-
munication reduce patient adverse events, specifically falls, pressure injuries, and
medication errors. These findings should be considered by clinicians to inform their
clinical handover practice.
1 | INTRODUCTION
Effective communication during the shift-to-shift nursing handover
has been the focus of international research for many years, as the
accuracy of information transferred can directly impact patient safety
(Halm, 2013; Wainwright & Wright, 2016).
Organizations such as the World Health Organization (WHO)
(2006) and the Australian Commission for Safety and Quality in
Health Care (ACSQHC) (2010) have identified communication during
clinical handover as a priority. Australia is leading international initia-
tives to improve clinical handover, having been designated as the lead
country to develop and implement standardized solutions as part of
the WHO (2006) Patient Safety Alliance "High Fives" initiative. This
KEYWORDS
medication administration errors, medication errors, nursing shift-to-shift handover, patient
adverse events, patient falls, pressure injuries
initiative focuses on supporting cross-national learning among seven
countries, using evidence-based protocols within five key patient
safety areas, including the prevention of handover errors.
During the past decade, several definitions of the clinical hand-
over have been identified, each focusing on the main functions and
purpose of this safety aspect of patient care (Jeffcott et al., 2009). A
commonly cited function of the clinical handover refers to the "trans-
fer of professional responsibility and accountability for some or all
aspects of care for a patient, or groups of patients, to another person
or professional group on a temporary or permanent basis” (British
Medical Association, National Patient Safety Agency, NHS Modernisa-
tion Agency, 2005, p. 7). Furthermore, ACSQHC emphasizes that the
transfer of responsibility and accountability for patient care includes
wileyonlinelibrary.com/journal/nhs
© 2021 John Wiley & Sons Australia, Ltd.
337 338
WILEY- Nursing & Health Sciences
structured communication tools and the opportunity for both the clini-
cians and patients to request, check, and confirm understanding of the
information discussed (ACSQHC, 2017). Communication failures during
the handover have been associated with poor patient outcomes includ-
ing inaccurate clinical assessment and diagnosis, delays in diagnosis,
delays in ordering tests, medication errors, inconsistent or incorrect
results interpretation, duplication of tests, increased rates of in-hospital
complications, increased length of hospital stay, and decreased patient
and staff satisfaction. In addition, it has been identified that ineffective
handover communication was one of the main root causes of greater
than 60% of sentinel or catastrophic patient events (The Joint
Commission, 2008). Therefore, it is essential that effective handover
communication is in place to ensure clear sharing of patient information.
The literature describes high variability in handover communica-
tion. This variability is related to the situation on which the handover
occurs (shift change, patient transfer, admission, or discharge), the
method (face to face, by phone, recorded, using electronic handover
tools), the place of handover (patient bedside, nurses station), and
those involved in the handover process (nursing, medical, multi-
disciplinary, patients and their families or carers). Various recommen-
dations are provided in the literature regarding the content and
processes of effective handover. The WHO (2007) recommends limit-
ing communication exchanges to only necessary information in the
handover process. Incorporating communication techniques such as
the Situation, Background, Assessment, Recommendations (SBAR) has
been suggested to provide a standard communication framework for
patient care handovers (WHO, 2007). Furthermore, the ACSQHC
(2010) developed the "Guide to Clinical Handover Improvement" to
assist with the introduction of a standardized handover approach
using a focused change management framework. This guide is based
on research conducted on medical and nursing shift-to-shift hand-
overs within acute care hospital settings and is intended for use by
healthcare teams to achieve the goal of clinical handover improve-
ment (ACSQHC, 2010). Consequently, during the past decade,
research has focused on developing evidence-based solutions for
improving clinical handover through improved and standardized
handover practices (Bukoh & Siah, 2020). Interventions such as the
implementation of bedside handover and adoption of standardized
handover tools (SBAR, ISBAR) have demonstrated positive outcomes.
These outcomes were reported as increased patient satisfaction with
the newly adopted handover style (Forde et al., 2020; Hada
et al., 2018; Sand-Jecklin & Sherman, 2014), increased nurse satisfac-
tion (Athwal et al., 2009; Jukkala et al., 2012; Thomas & Donohue-
Porter, 2012), decreased nursing workload (Bradley & Mott, 2012;
Chung et al., 2011; Jukkala et al., 2012) and increased patient safety
outcomes such as reduction in patient adverse events and complica-
tions (Bradley & Mott, 2012; Chaboyer et al., 2010; Hada et al., 2018).
A Cochrane systematic review conducted by Smeulers et al.
(2014) explored the effectiveness of interventions designed to
improve hospital nursing handover, specifically to identify interven-
tions associated with improved patient outcomes (medication errors,
complications, sentinel events or mortality) or improved process of
care outcomes (information provided, compliance with the plan of
HADA AND COYER
care, timely delivery of care, decrease in information omissions). This
review was limited to randomized controlled trials (RCT) and found no
eligible studies; therefore, Smeulers et al. (2014) identified there was
no evidence available to support conclusions about the effectiveness of
nursing handover interventions for ensuring continuity of information
exchanges of hospitalized patients (Smeulers et al., 2014). Furthermore,
Mardis et al. (2017) conducted a systematic review of studies published
January 2008 to May 2015 and focusing on shift-to-shift handover inter-
ventions associated with improved patient outcomes. The patient out-
comes included inpatient falls, reportable events, length of stay,
mortality, code calls, medication errors, medical errors, procedural com-
plications, pressure ulcers, weekend discharges, and nosocomial infec-
tions. The findings of this review showed that while most studies
demonstrated improvements in various patient outcomes, because of
the heterogeneity of methods, limited number of studies, and inconsis-
tent findings, there were no firm conclusions about specific interventions
and associated outcomes (Mardis et al., 2017).
Similarly, an integrative review of the different nursing handover
models and processes available conducted by Bakon et al. (2017) con-
cluded that while a structured handover can enhance patient safety
through error prevention, there is no strong evidence that any model dis-
plays superior efficacy (Bakon et al., 2017). Furthermore, Bukoh and
Siah (2020) found no statistically significant results in their systematic
review of literature published up to January 1, 2019, exploring the effec-
tiveness of structured handovers in improving inpatient outcomes. How-
ever, Bukoh and Siah (2020) included only RCTs and quasi-experimental
studies in their review. This integrative review has adopted a broader
approach to include both experimental and nonexperimental studies. Fur-
thermore, patient outcomes reported by Bukoh and Siah (2020) included
general patient complications, nursing-related medication errors, and gen-
eral adverse events, whereas this current review has explored handover
interventions specifically associated with reductions in the incidence of
inpatient falls, pressure injuries, and medication administration errors.
It is evident that the focus on interventions aimed to reduce the risk
of miscommunication or omission of essential information during the
clinical handover has increased. However, it has been highlighted that
strong evidence from high-quality studies to determine the effectiveness
of interventions designed to improve the nursing handover communica-
tion is still required (Bakon et al., 2017; Bressan et al., 2019).
Given the ongoing imperative to improve patient safety through
communication in the handover process (Holly & Poletick, 2013), it is
important to understand the effectiveness of interventions aimed at
improving nursing handovers. Implementing practice changes for
which the evidence is of poor quality poses the risk of wasting valu-
able resources and the clinicians could be reluctant to implement
other initiatives (Bressan et al., 2019).
2 | AIMS
The aim of this review was to determine the nursing interventions
designed to improve shift-to-shift nursing handover communication and
specifically to identify which interventions were associated with HADA AND COYER
improved patient safety outcomes (reduction in the incidence of falls,
pressure injuries, and medication administration errors) in the adult acute
hospital setting.
3 | METHODS
An integrative review approach was used to allow the inclusion of
diverse methodologies, including experimental and nonexperimental
studies, which has the potential to enhance the application of findings
from diverse data sources to clinical practice and evidence-based
practice nursing initiatives (Whittemore & Knafl, 2005).
The protocol is registered on the International Prospective Regis-
ter of Systematic Reviews (PROSPERO ID: CRD42019147261). The
Preferred Reporting Items for Systematic reviews and Meta-Analyses
(PRISMA) statement (Moher et al., 2009), and the Cochrane Hand-
book for Systematic Reviews of Interventions (Higgins &
Green, 2008) were used to guide the review process.
3.1 | Review question
For acute care in-hospital adult patients what interventions designed
to improve shift-to-shift nursing handover communication when com-
pared to standard practice are associated with improved inpatient
outcomes (decrease in falls, pressure injuries, and medication errors)?
3.2 | Search methods
An electronic search was conducted by AH in seven databases: Cumu-
lative Index of Nursing and Allied Health Literature (CINAHL);
Cochrane Library (including Cochrane Central Register of Controlled
Trials, Cochrane Database of Systematic Reviews); Dynamed;
MEDLINE; PubMed; ProQuest; and The Joanna Briggs Institute for
Evidence Based Nursing and Midwifery. Searches were restricted to
articles published in English between January 2007 (following the
release of the WHO "High Fives" initiative in December 2006) and
July 2020. Single search terms and combinations of terms were used
and joined by Boolean connectors and medical subject heading
(MeSH) terms: adverse events, continuity of patient care, handover,
handoff, handover communication, intervention, improvement, medi-
cation errors, nursing, patient falls, patient outcome, pressure injuries,
quality initiative, quality of care, shift report, and transfer of care.
Boolean operators included "and," "or," and "within." An example of
search strategy in PubMed is presented in Appendix S1.
3.3 | Eligibility criteria and study selection
The Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) diagram (Moher et al., 2009) is presented to show
the study selection process (Figure 1).
Nursing & Health Sciences -WILEY 339
Studies that met the following criteria were included:
Studies: Prospective or retrospective quantitative, qualitative, and
mixed-methods studies published in English between January 1, 2007,
and July 31, 2020
Interventions: Any nursing intervention designed to improve nurs-
ing handover compared with a previous or existing nursing handover
practice or an alternative intervention
Outcomes: Objectively measured quantitative and/or qualitative
data reporting on inpatient outcomes (falls, pressure injuries, and
medication errors)
Studies conducted in emergency departments, intensive care
units, operating theaters, perioperative areas such as postanesthesia
care units, mental health units, and outpatient and ambulatory depart-
ments were excluded as different formats of nursing handovers in
these settings might not be consistent with those in acute inpatient
wards. Studies conducted in subacute, rehabilitation, and oncology
inpatient units were included.
Retrieved articles were screened to remove duplicates and were
assessed independently by two independent reviewers (AH and FC)
by title and abstract against the inclusion criteria. Consensus for inclu-
sion was achieved through discussion. Then, the same two reviewers
independently screened the full-text articles that met the inclusion
criteria.
3.4 | Methodological quality assessment
The Mixed Methods Appraisal Tool (MMAT), Version 2018, was
used to rate the methodological quality of all eligible studies. This
tool is designed to appraise the methodological quality of differ-
ent categories of studies: qualitative research, randomized con-
trolled trials, nonrandomized studies, quantitative descriptive
studies, and mixed-methods studies (Hong et al., 2018). Further-
more, the MMAT is based on a literature review of systematic
mixed study reviews (Pluye, 2013), has recognized content valid-
ity and has been pilot-tested across all methodologies (Pace
et al., 2012). After responding to two screening questions, each
included study was rated in the appropriate category of criteria as
either "yes," "no," or "cannot tell" (Table 1). While the
2018 MMAT version does not include a scoring system, it pro-
vides a detailed presentation of the criterion for each of the rat-
ings to inform the quality of included studies (Stretton
et al., 2018). The two reviewers (AH and FC) independently rated
studies, with a third person (LJ) consulted when consensus on
assessment scores could not be reached.
3.5 | Data extraction
The following data were extracted from eligible studies using a stan-
dardized data collection form constructed with reference to Cochrane
guidance (Table 2): author (year, country), design, sample, cohort,
intervention, measures, main findings, and limitations. 340
WILEY- Nursing & Health Sciences
Identification
Screening
Eligibility
Included
Records identified through database
searching
3.6 | Data analysis
(n = 435): CINAHL (n = 134)
Cochrane Library (n = 1), Dynamed (n
= 85), Medline (n = 67) PubMed (n=
33), ProQuest (n = 43), JBI (n = 72)
Total records identified (n = 452)
Records after duplicates removed
(n = 186)
Quantitative
(n = 5)
Records screened
(n = 186)
Additional records identified
through other sources
(n = 17)
Full-text articles
assessed for eligibility
(n=29)
Studies included
(n = 8)
FIGURE 1 Flow diagram of study searches and records (PRISMA, 2009)
Descriptive and summary statistics (means, standard deviations) were
used to analyze the quantitative data. There was substantial heteroge-
neity regarding the interventions and outcome measures in the
included studies; thus, the initial intention of pooling the quantitative
study results was not a valid approach (Field & Gillett, 2010). The find-
ings are therefore presented as a narrative summary (Popay
Records excluded
(n = 157)
Full-text articles
excluded,
(n=21) reasons: no
design or method
stated, no clear
results reported,
Mixed methods
(n = 3)
HADA AND COYER
et al., 2006). The three outcome measures-falls, pressure injuries, and
medication errors-provided the framework for analysis of the rela-
tionships within and between studies to guide an overall assessment
of the robustness of the evidence. Furthermore, a qualitative thematic
analysis of pooled data to assess emergent themes was not performed
as there were no qualitative data in the included studies related to
nursing handover interventions associated with improvements in falls,
pressure injuries, and medication errors. TABLE 1
Mixed methods appraisal tool
First author
Year
Screening questions
1. QUALITATIVE STUDIES
2. RANDOMIZED CONTROLLED TRIALS
3. NON-RANDOMIZED STUDIES
4.QUANTITATIVE DESCRIPTIVE
STUDIES
S1. Are there clear research questions?
S2. Do the collected data allow to address the research
questions?
1.1. Is the qualitative approach appropriate to answer the
research question?
1.2. Are the qualitative data collection methods adequate to
address the research question?
1.3. Are the findings adequately derived from the data?
1.4. Is the interpretation of results sufficiently substantiated
by data?
1.5. Is there coherence between qualitative data sources,
collection, analysis and interpretation?
2.1. Is randomization appropriately performed?
2.2. Are the groups comparable at baseline?
2.3. Are there complete outcome data?
2.4. Are outcome assessors blinded to the intervention
provided?
2.5 Did the participants adhere to the assigned intervention?
3.1. Are the participants representative of the target
population?
3.2. Are measurements appropriate regarding both the
outcome and intervention (or exposure)?
3.3. Are there complete outcome data?
3.4. Are the confounders accounted for in the design and
analysis?
3.5. During the study period, is the intervention administered
(or exposure occurred) as intended?
4.1. Is the sampling strategy relevant to address the research
question?
4.2. Is the sample representative of the target population?
4.3. Are the measurements appropriate?
4.4. Is the risk of nonresponse bias low?
4.5. Is the statistical analysis appropriate to answer the
research question?
Athwal
2009
No
Cannot
tell
Bradley Burston Chaboyer
2012
2015
Yes
Yes
Yes
Yes
Yes
Yes
2010
Yes
Yes
Yes
Yes
Yes
Yes
Cannot
tell
Yes
T
Yes
Yes
Sand-
Jecklin
2014
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Sand-
Jenklin
2013
Yes
Yes
Cannot tell
Yes
Yes
Cannot tell
Cannot tell
Johnson
2016
Yes
Yes
Yes
Yes
Yes
No
Yes
Hada
2018
Yes
Yes
Yes
Yes
Yes
Yes
Yes
(Continues)
HADA AND COYER
Nursing & Health Sciences –WILEY 341
