Avoidable medical errors account for approximately 250 000 deaths annually in the United States.1 Two of the primary root causes of medical errors in the healthcare setting are miscommunication and cognitive lapses, which account for 100 000 deaths per year.2,3 The cognitive lapses are attributed to the healthcare provider experiencing cognitive overload, which impedes his/her ability to recall essential patient information from the transfer of care.4,5 In addition, 80% of all healthcare sentinel events are related to miscommunication occurring during the transfer of patient care between healthcare providers.6,7 Handoff communication errors continue to be a primary cause of poor patient outcomes despite the continued research focus on handoff over the past 10+ years.8 We present a study that examined the message that is communicated in the nursing handoff in terms of data, information, and knowledge and the potential impact on the nurses' cognitive processing capacity.
BACKGROUND
The handoff of patient care is defined as the transfer of patient care responsibility, patient information, and the authority to initiate care interventions from one healthcare provider to another.9-13 The transfer of patient care communication has several different labels, but for the purposes of this study, we will use the terms "nurse-to-nurse change-of-shift handoff communication" or "nursing handoff." The nurse-to-nurse change-of-shift handoff communication is a cognitively intense process requiring the nurses to simultaneously accurately recall patient information and analyze and synthesize a vast amount of patient data, information, and knowledge in a condensed time period.11,14,15 The nursing handoff process is vulnerable to miscommunication due to interruptions, distractions, and cognitive overload.15-17 The primary purpose of the nursing handoff is to communicate essential patient data, information, and knowledge from one nurse to another to ensure the continuity of safe patient care.15,18,19 Nurses use the data, information, and knowledge obtained through the nursing handoff to gain situational awareness and situational understanding and to make informed clinical patient care decisions.
Data, Information, and Knowledge
The use of data, information, and knowledge to improve patient outcomes is the foundation of nursing informatics.20,21 The term "information" is a generic word used widely to describe what is communicated verbally or in writing (data, information, and knowledge).22 What are the differences among the terms "data," "information," and "knowledge"? An extensive literature review was conducted to develop current working definitions for data, information, and knowledge. Data are raw, individual, unrelated facts that independently have no meaning.20,23,24 Information is one data point connected to another data point, creating meaning and organizing the data into information.23,24 Knowledge is the process of synthesizing and connecting an information segment to another information segment, creating deeper meaning, context, and conceptual understanding.23,24 When nurses are engaged in the interactive collaborative nursing handoff process, they are sharing patient data, information, and knowledge.15,25Table 1 provides definitions and examples of data, information, and knowledge.
Cognitive Overload
Cognitive overload occurs when the volume of information received by individuals exceeds the capacity of their cognitive processing ability.5 The end result of cognitive overload is the inability to recall information, discern irrelevant information from relevant information, and complete a task.26 The nurse-to-nurse change-of-shift handoff communication is susceptible to cognitive overload due to two primary factors: the healthcare system and what is being communicated in terms of data, information, and knowledge. Healthcare systems have evolved into sociotechnical systems requiring the nurses to process human-to-human and human-to-computer interactions simultaneously to complete a workflow task.27,28 In addition, the content of the message in terms of how much data, information, or knowledge impacts the individuals' cognitive processing capacity.15 A higher percentage of data in the message results in the nurse using more cognitive processing capacity to understand what is being communicated and an increase in the nurses' cognitive load.
PURPOSE
The increased cognitive load experienced during the nursing handoff due to environmental factors and what is being communicated leads to cognitive overload resulting in nurses inaccurately recalling relevant patient information.8 Nursing handoff research has been primarily focused on the structure, form, and consistency of the nursing handoff communication.15 There has been minimal research exploring what is being communicated during the handoff in terms of data, information, and knowledge. In addition, there are no studies comparing bedside nursing handoff communication with nonbedside nursing handoff.8,15 The aim of this study is to examine the content in terms of data, information, and knowledge of the nurse-to-nurse change-of-shift handoff communication (bedside and nonbedside) of a patient who has experienced a clinical event (CE). A CE is an unexpected change in patient condition in one of the following areas: pain, fever, bleeding, change in respiratory status, change in level of consciousness, and change in output.29
Framework
The Nurse-to-Nurse Transition of Care Hand-off Communication Framework was developed and used as a framework for exploring the phenomenon of the nurse-to-nurse change-of-shift handoff communication. The framework was developed as part of a dissertation study and needs additional theoretical testing. The theory derivation and reformulation were used in creating the framework from selected concepts and the associated assumptions and relationships with the Effective Nurse-to-Nurse Communication Framework29 and the Cognitive Load Theory.5 The Effective Nurse-to-Nurse Communication Framework contributed to the structure, assumptions, and relationships aligned with communicating patient information. The Cognitive Load Theory provided a framework for understanding human cognition, the processing of incoming information from multiple sources, and the development and impact of cognitive overload.
The Nurse-to-Nurse Transition of Care Hand-off Communication Model provides the framework to examine, describe, and predict the flow of data, information, and knowledge from one nurse to another both verbally and electronically.15 If a CE occurs, the off-going nurse must efficiently process and prioritize the information to accurately recall relevant patient information for the nursing handoff. The off-going nurse uses both written and electronic notes to verbally communicate relevant patient information throughout the nursing handoff. The oncoming nurse must process and merge the information received verbally and electronically to be able to effectively recall relevant patient information when needed. In summary, the model frames the flow of patient information from one nurse to another at the transition of care and identifies potential explanations of miscommunication and cognitive overload.
METHODS
Design
A qualitative descriptive design was used to explore the content of nurse-to-nurse change-of-shift handoff communication in terms of "what" is being communicated in terms of data, information, and knowledge. The qualitative descriptive design was used for this study because little is known about the content of the nursing handoff, and we are seeking to answer the "what" of the phenomenon of interest.
Trustworthiness
Trustworthiness in this study was established using the COnsolidated criteria for REporting Qualitative research Checklist30 and naturalist methodology: truth-value, applicability, consistency, and neutrality.31,32 Truth-value (credibility) was established by using triangulation of data sources and triangulation of data analysis. We demonstrated applicability (transability) by providing a detailed description of setting, sample, the participants, and research protocol. Consistency in the study was established by using a detailed chronological audit trail. The primary investigator (PI) used reflexivity and coanalysis of the data to minimize bias and establish neutrality (confirmability) in the results.
Setting
Institutional review board approval was received from both the PI's academic institution and the healthcare institution. The setting for the study was a not-for-profit urban medical center in Colorado, a medical-surgical unit where patients had a medical health threat or had or were scheduled for a surgical procedure. The unit selected performed the nursing handoff at both bedside and nonbedside. In addition, the nursing unit did not use a standardized handoff form or an electronically generated health record form.
Recruitment and Sample
The subject of this study was the nursing change-of-shift handoff communication, and the participants were the nurses who performed the handoff. No recruitment activities such as advertisements, brochures, or bulletin board postings were used for this study. The PI obtained the nursing unit's manager's approval prior to data collection. Convenience purposive sampling was used to identify and obtain the nurse participants for the study. Inclusion registered nurse (RN) criteria for participation in the study were as follows: (1) worked full time on a medical-surgical unit; (2) a minimum of 3 months' experience on the medical-surgical unit and off orientation; (3) had provided care or was continuing to provide care for a patient who had experienced a CE; and (4) was able to speak and read English. In addition, the RN could be a traveling or agency nurse but not a float RN. The RNs were allowed to participate only once in the study to prevent potential Hawthorne effect influencing the data. The sample size for this study was of 10 handoff dyads. A handoff dyad is one nurse (off-going) giving the report and one (oncoming nurse receiving). The sample consisted of 10 off-going nurses and nine receiving nurses for a total sample size of 19 RNs (n = 19).
Data Collection
The setting for the data collection was both at the bedside of the patient and nonbedside. The data collected for this study were the audio-recorded nurse-to-nurse change-of-shift handoff communication bedside and nonbedside. In addition to the digital audio recordings, field notes were kept for each day of data collection. A structured data collection procedure was followed throughout the data collection process. The PI was the only individual consenting and collecting the data. The PI arrived on the unit 45 minutes prior to the start of the next shift. The nursing unit had a large whiteboard that listed the patient room numbers and the assigned nurse. Nurses listed in red or with another nurse by a patient room indicated that the nurse was on orientation. The PI reviewed the whiteboard to identify potential nursing handoff dyads who met the inclusion criteria for participation. The PI approached both the off-going and oncoming RNs to discuss the study and obtain consent to participate in the research study. If the nursing handoff was recorded in the patient room, then the PI approached all individuals in the patient's room, explained the study, and consented each person in the room prior to data collection.
Data collection commenced after all consents were obtained. When the handoff dyad was ready to do the nursing handoff, the PI would start a digital audio recorder and step back to reduce a potential Hawthorne effect. When the handoff was complete, the dyad signaled the PI, and the PI turned off the digital audio recorder. The same procedure was followed until five bedside and five nonbedside nurse-to-nurse change-of-shift handoffs were digitally audio recorded. In addition to collecting the nursing handoff communications, general demographic information was collected on each participant.
Data Management and Data Analysis
The five bedside and five nonbedside recorded handoffs were transcribed by the PI. The PI alphanumerically coded the nursing handoffs as follows: "bedside handoff 1," "nonbedside handoff 1," and so on until a total of 10 handoffs was reached (five bedside and five nonbedside handoffs). The PI transcribed the 10 nursing handoffs verbatim and used the following deidentification procedure: patient's name and room number were transcribed as "patient," nurse's name as "nurse," provider's name as "provider," and so forth. The nurse-to-nurse change-of-shift handoff transcriptions were confirmed for accuracy by the PI's research advisor. Once accuracy was confirmed, the digital audio recordings were transferred to the academic institution's secure cloud storage and deleted from the PI's computer and the digital audio recorder.
Content analysis was used to analyze the nurse-to-nurse change-of-shift handoff communication for the presence of data, information, and knowledge. The content analysis coding strategy used for this study was hypothesis coding. Hypothesis coding is an exploratory content analysis strategy that uses predefined codes based on what the PI predetermines is present in the text data.33 The PI used the priori definitions for data, information, and knowledge (Table 1). Excel (Microsoft Inc., Redmond, WA, USA) was used in the analysis process to organize the transcribed handoff content into segments and then coded into data, information, or knowledge categories.
RESULTS
Demographics
The sample size of the study was 10 handoff dyads consisting of 19 RNs. One RN was the receiving nurse on two separate nursing handoffs on the same change of shift. The 19 RNs consisted of 73.7% female (n = 14) and 26.3% male (n = 5). The sample was primarily identified as White, 57.9%. The highest education level of the nurse participants was 47.4% associate degree in nursing and 52.6% BSN. For the overall years of experience as an RN, 57.9% had 3 months to 3 years of nursing experience, with a mean of 4 years of nursing experience. The RN participants reported that 78.9% had 3 months to 3 years of nursing experience working on this particular nursing unit with a mean of 2 years of RN experience on this medical-surgical floor.
Data, Information, and Knowledge
The bedside and nonbedside nursing handoffs data were cleaned prior to data analysis. Cleaning of the handoff data consisted of deidentifying all protected health information as described in the data management section. The bedside and nonbedside handoffs were then analyzed for the presence and frequency of occurrence of data, information, and knowledge. As previously described, the content analysis strategy used in this study was hypothesis coding. The handoffs overall were coded into 176 individual segments consisting of data (n = 61), information (n = 91), and knowledge (n = 24). The bedside nursing handoff contained a total of 95 coded segments of data (n = 26), information (n = 56), and knowledge (n = 13). The nonbedside nursing handoff contained 81 individual coded segments of data (n = 35), information (n = 35), and knowledge (n = 11). The results are presented in the following order: an overview of the 10 nursing handoffs and then a comparison between the five bedside and five nonbedside nursing handoffs.
Overview of the Handoff
The percentage of the frequency of data, information, and knowledge occurring in the handoff was calculated by dividing each category by the total number of coded segments (n = 176). The nurse-to-nurse change-of-shift handoff communication comprised 34.7% data, 51.7% information, and 13.6% knowledge. The percentages of the occurrence of data, information, and knowledge in the overall handoff, bedside handoff, and nonbedside handoff are provided in Table 2. In addition, exemplars of data, information, and knowledge communicated in the nurse-to-nurse change-of-shift handoff are presented in Table 3.
Bedside Versus Nonbedside Handoffs
The same method used to calculate the percentage of the frequency of data, information, and knowledge occurring in the overall handoff was used to calculate bedside and nonbedside handoffs' frequency percentages. The total number of coded segments in the bedside nursing handoff was 95, and nonbedside handoff was 81. The nonbedside handoff when compared with the bedside handoff consisted of a higher percentage of individual data elements at 43.2% and 27.4%, respectively. In addition, the nonbedside handoff comprised a lower percentage of information that was communicated at 43.2% as compared with 58.9% for the bedside handoff. The bedside and nonbedside nursing handoffs contained essentially the same percentage of knowledge in the handoff communication at 13.7% and 13.6%, respectively. Table 3 provides a side-by-side visual comparison of the percentage of frequency for overall handoff, bedside handoff, and nonbedside handoff.
DISCUSSION
The aim of this study was to examine the content in terms of data, information, and knowledge of the nurse-to-nurse change-of-shift handoff communication of a patient who has experienced a CE and compare bedside with nonbedside handoff. Digital audio recordings of the handoff were collected and analyzed to address the research aim of this study. The nurse-to-nurse change-of-shift handoff communication primarily comprised data (34.7%) and information (51.7%), with minimal knowledge (13.6%) being shared. These results are similar to the study by Matney et al25 examining the presence of data, information, knowledge, and wisdom in the handoff communication. A possible rationale for the low percentage of knowledge in the nursing handoff is the experience level related to the number of years on this medical-surgical unit and total years of experience as a nurse. An additional factor could be attributed to the education level, but the nurses in this study were 47.4% associate degree in nursing and 52.6% BSN prepared.
The literature review did not reveal any previous studies comparing or investigating the presence of data, information, and knowledge between nonbedside and bedside handoffs. An interesting finding from this study when comparing the bedside with nonbedside handoff communication is the percentage of data and information communicated in each by the nurses, respectively. The RNs giving the bedside handoff communicated a substantially lower percentage of data at 27.4% as compared with RNs giving a nonbedside handoff, which contained 43.2% data. The RNs providing the handoff at the bedside communicated 58.9% information as compared with 43.2% for the RNs giving a nonbedside handoff. At present, there is no documentation on what the "ideal" percentage of the handoff content should be in terms of data, information, and knowledge. We do not have sufficient data to make a recommendation in this article. What is known based on the Nurse-to-Nurse Transition of Care Hand-off Communication Framework is that how information is presented and communicated does affect the receiving individual's ability to effectively process and then recall relevant information.5,15,34
The amount and mix of data, information, and knowledge that is communicated during the nursing handoff communication do impact the nurses' cognitive load. When we communicate individual data elements such as a blood pressure reading, respiratory rate, and intake and output, the person receiving the message must then create information and knowledge out of those data elements. The process results in the receiving individual using more cognitive space to create the information and provides less available cognitive processing capacity to comprehend, synthesize, and recall patient information.5 An increase in the percentage of data components in the handoff amplifies the noise or the static potentially interfering with the message being effectively communicated and processed.15,29,35
The nurses receiving the handoff in this study were processing a higher percentage of data and information rather than knowledge statements. The nonbedside handoff potentially places a greater strain on the nurses' cognitive processing ability as compared with the bedside handoff due to the increased amount of data in the message. The nurses receiving the handoff at the nonbedside have a higher potential for experiencing cognitive overload due a higher percentage of data occurring in the message. The higher amounts of data in the message occupy more of the receiving nurses' cognitive processing space leading to cognitive overload and the inability to recall relevant information.4,36,37 If nurses communicate more information and knowledge in the handoff, the RNs receiving the handoff will be able to more efficiently process the information and avoid experiencing cognitive overload. Prior research on cognitive processing indicates that the capacity to process incoming information increases when more information and knowledge are received because the individual is able to activate long-term memory, and this results in the person's ability to recall more relevant information.4,5,36 Nurses are highly capable of communicating the patient's story in the form of information and knowledge and increase the ability of the receiving RN to recall more relevant patient information.
FUTURE RESEARCH
We recommend that future research examine how the data, information, and knowledge communicated during the handoff correlate with how the same information is communicated and presented in the EHR. Is the EHR capable of communicating the same or similar nursing information and knowledge that is provided in the nursing handoff? We need to further explore how our current EHR and clinical decision support systems could better assist the communication of nursing knowledge during the handoff. Further, what innovative technological applications or interventions could be used to enhance the communication of nursing knowledge during the handoff?
Additional research on nursing handoff communication is needed to further explore and identify possible reasons why nurses communicate minimal knowledge during the handoff. Does the experience level in terms of number of years working on a unit and the total years as a nurse influence the amount of data, information, and knowledge communicated in the handoff message? Does the education level for entry to practice influence what is communicated in the nursing handoff data, information, or knowledge? Research is needed to explore if there is a difference in the amount of data, information, and knowledge communicated in the handoff on a medical-surgical unit and a specialty unit such as an intensive care, step-down, or cardiovascular unit. We would invite and encourage further testing of the Nurse-to-Nurse Transition of Care Hand-off Communication Model.
LIMITATIONS
Even though the study did address a gap in the handoff research regarding what is being communicated in terms of data, information, and knowledge, there are acknowledged limitations in this study. The study was conducted in one urban medical center on a single medical-surgical unit that did not use a standardized handoff instrument. The results of this study cannot be transferred or compared with other medical-surgical units or other medical centers because of potential differences in organizational and unit cultures and the possible use of a standardized handoff instrument. The use and type of standardized handoff instruments used in nursing are not consistent across all nursing areas.8
CONCLUSION
The purpose of this study was to examine the "what" of the nurse-to-nurse change-of-shift handoff communication in terms of the data, information, and knowledge communicated in the message. The Nurse-to-Nurse Handoff Communication Model was used to structure and guide this research. This study addressed a gap in the research of "what" is being communicated (data, information, and knowledge) in the nursing handoff communication. A total of 10 nursing handoffs, five bedside and five nonbedside, were digitally audio recorded and analyzed using the content analysis technique of hypothesis coding. The nursing handoff consisted primarily of data and information, with minimal knowledge being communicated by nurses. The bedside handoff did contain substantially more information and fewer data as compared with the nonbedside handoff. This study contributed data and evidence to the nursing literature that the handoff communication between nurses at bedside and nonbedside is different. The difference in the communication has the potential to negatively affect patient satisfaction and outcomes.
References