HANDOFFS, the transition of responsibility for a patient's care from one provider to another, have been identified as significant potential sources of communication errors for hospitalized patients.1 In 2006, The Joint Commission identified standardized handoff communication as one of their National Patient Safety Goals. Since then, the regulatory agency has moved this into a standard of performance that includes an added requirement that patients be encouraged to actively participate in their care during the handoff communication process.2 One means of encouraging this active participation is to conduct the end-of-shift handoff between nurses at the patient's bedside, allowing the patient and family to participate in the process. Bedside handoff with patient engagement not only meets the Joint Commission standards but also contributes to improved patient safety.3,4
Reports of patients' perspectives of bedside handoff have been qualitative, anecdotal, or have used indirect measurement tools such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or proprietary surveys.5-9 While information gathered by these methods provides valuable feedback to hospitals and their nursing staffs, it is possible that reports of increases in positive responses to these tools could be due to a number of factors and not only the practice of bedside handoffs. The purpose of this study was to identify patients' perceptions of the bedside handoff by means of direct and quantitative measurement.
REVIEW OF LITERATURE
As Riesenberg et al10 noted in their systematic review, the published research on handoffs was of relatively low quality when evaluated on the scale they developed for their review. Although they identified consistency in the literature, the reports were based primarily on anecdotal evidence. While there have been additional studies published since this review,10 there has been little evidence published that demonstrates the extent to which patients are included in the bedside handoff process, or if patients believe that the bedside report process enhances their understanding of and participation in their care.11 The majority of published studies have focused on the implementation of bedside handoffs3,5,12-14 and nurse perceptions of the process.9,14,15
Several of the studies that reported on implementation and nurse perceptions also included anecdotal findings of patient perceptions. Webster16 concluded that patients and their families "appear more relaxed and team members appear highly interactive/communicative with patients during the hand-over process."(p1382) However, Webster's observations were not quantified in any way.
Anderson and Mangino5 described patients' satisfaction with the bedside handoff process. This report was based on patient interviews collected during leadership rounding, not as the findings from any formal investigation. Chaboyer et al12 also reported that patients perceived the change to bedside handoffs positively and concluded that patients were more active participants in their care and had a clearer understanding of the plan for their care when handoffs occurred at the bedside. However, this information was collected in informal interviews with patients. Chaboyer et al12 do not report details on either their sample or the specific questions that were asked.
Published studies designed to determine patients' perceptions of bedside handoffs have been primarily qualitative. Cahill,6 in one of the earliest studies on this subject, found that patients identified themes that included maintenance of professional dominance by nurses, establishment of professional sharing between nurses, and maintenance of patient safety. Cahill reported that patients perceived that the primary purpose of bedside handoffs was to keep them safe. McMurray et al17 came to the same conclusion in 2011. Patients identified that bedside handoff gave them an opportunity to correct inaccuracies or misinformation in the nurses' handoffs. Patients also reported that the bedside handoff helped them to create personal connections with their nurses, enhanced their awareness of care and status, and gave them an opportunity to exercise choices in their level of participation in the handoff.14
More recently, researchers have published reports that seek to measure quantitatively the outcomes of using bedside handoffs. Improvements in patient satisfaction survey scores, including proprietary surveys,8,9 have been demonstrated. These improvements in scores have been attributed to the implementation of bedside handoffs; however, no specific questions were asked about the use of bedside handoff. Anderson and Mangino described improved scores for several items on proprietary surveys after implementation of bedside handoffs, including "Nurses kept you informed"; "Staff worked together to care for you"; and "Staff include you in decisions regarding treatment."5(pp120-121) The authors do not report whether the changes were statistically significant. Tidwell et al9 reported improvements in items asking about satisfaction with nursing care and communication, as did Thomas and Donohue-Porter,18 who closely monitored their proprietary survey responses in conjunction with their implementation of bedside handoff. In this study, the items "Nurses kept you informed"; "Friendliness and courtesy of staff"; and "Likelihood to recommend" all demonstrated improvements with the implementation. Again, no statistical significance was reported.18
The HCAHPS scores also have been used to demonstrate the effectiveness of bedside handoffs. Improvements in scores for communication have been demonstrated7 after the implementation of bedside handoffs.
Studies in which patients were asked directly about the handoff have been published in recent literature. Patients have been asked to provide their perceptions after changes in the handoff process were implemented. These studies report increased satisfaction with being treated with respect, listened to by nurses, and staff members' teamwork in caring for patients.19,20
One study explored patients' perceptions of bedside handoffs both quantitatively and qualitatively.21 In their responses to the quantitative survey, patients indicated that they agreed with statements about asking questions, understanding their care, having confidence in their providers, and participating in their care. This sample also included parents of pediatric patients. Themes identified during follow-up interviews with a subset of the sample reinforced the importance of collaborating and communicating with patients, engaging them in their care, and giving patients and parents an opportunity to inform their nurses of important information about themselves or their children.
The literature indicates that bedside handoffs lead to increased patient satisfaction with their care, increased involvement in their care, and the perception that nurses are acting to keep patients safe while hospitalized.5,12,14,16,17 The aim of this study was to identify patients' perceptions of bedside handoffs by directly asking patients about their experiences.
METHODS
Setting
The study was conducted on 2 inpatient medical-surgical departments at Borgess Medical Center, a regional medical center in southwest Michigan. Both departments provide telemetry monitoring and care for patients 13 years and older. The two 46-bed departments had implemented bedside handoffs at change of shift 18 months prior to the beginning of this study. Institutional review board approval was obtained from the hospital and a local university.
Prior to the implementation of bedside handoff, the nursing staff conducted face-to-face verbal handoffs at nursing work stations located outside patient rooms during shift change. After the change in practice, the handoff was conducted between the offgoing and the incoming nursing staff at the patient's bedside. The process is standardized in a situation-background-assessment-recommendation format and uses a nursing communication tool embedded within the electronic health record. In addition to the exchange of patient data, the bedside handoff implementation provides the incoming nurse with the opportunity for immediate visualization of the patient and opportunity to establish a foundational trusting relationship with the patient.
Sample
A convenience sample of prospective patient participants was identified from the inpatient census of the 2 nursing departments. Before approaching any patient to discuss the study, a research assistant consulted the assigned registered nurse (RN) to determine if the patient met the inclusion criteria for the study. These criteria included age more than 18 years, fluency in spoken and written English, and no diagnosis of dementia or confusion. All subjects had to meet the hospital's criteria for informed consent, had to have spent their entire stay in the study department, and had to have experienced at least 3 handoffs. Respondents were not automatically excluded from the study if they indicated a lack of certainty about bedside handoff. During the informed consent process, the research assistant conducted a review of the bedside handoff process with a teach-back approach for clarity. Subjects were reminded that they could respond "Never" to the question of how often bedside handoff was done, and to follow the instructions on the survey as to how to proceed. A total of 103 patients who met the inclusion criteria were surveyed.
Survey development
Houser and Bokovoy22 suggest that for survey research, a sample of 15 participants for each variable is the minimum requirement. The survey items were categorized into 4 variables including understanding, participation, safety, and satisfaction, which suggested a sample size of 60. The survey was designed to collect demographic information (age, gender, education level, and ethnicity); frequency of bedside handoff experiences; and perceptions of the handoff. A set of 8 items was derived from Institute of Medicine recommendations23 and HCAHPS24 survey themes. A 4-point Likert type scale ranging from 1 (strongly disagree) to 4 (strongly agree) was designed to capture patient perceptions. An open-ended optional comment box concluded the survey.
The instrument was reviewed for content validity by nurse experts from the organization, including clinical nurse specialists, managers, nurse educators, a PhD-prepared nurse researcher, and staff RNs. Several nonclinical hospital personnel also reviewed the survey items for face validity. The survey was revised on the basis of their feedback. Cronbach [alpha] for the instrument was 0.92.
Data collection and analysis
Once it was determined that a patient met the inclusion criteria, a research assistant approached the patient to introduce the study and invite the patient to participate. The research assistant obtained informed consent and then left the room while the patient completed the paper survey and placed it in a sealed envelope. When the research assistant returned to collect the survey, the patient was given a $5 gift card to a local grocery store as a token of appreciation. Participant recruitment and data collection occurred between December 2011 and June 2013.
Descriptive statistics were used to summarize the sample. Pearson correlation was used to determine if there were relationships between patients' demographic characteristics and their responses to individual items, and also to determine if significant relationships existed between the frequency of bedside handoff and responses to individual items. The IBM Statistical Package for the Social Sciences, version 20 for Windows25 was used to analyze participant responses.
RESULTS
All subjects who enrolled went on to complete the survey. There was equal representation of genders. Slightly more than half of the participants (51%) were between 60 and 79 years old. The majority (81.7%) described themselves as Caucasian or White with at least a high school education (51.5%). This sample was representative of the medical center's patient demographics. No significant correlations between demographic characteristics and any of the survey items were identified with Pearson correlation.
Sixty-five (63.1%) of the patients surveyed reported that they "always" experienced bedside handoff during their stay. An additional 26 (25.2%) patients indicated that they experienced bedside handoff "most of the time." Six (5.8%) patients reported that they "rarely" experienced bedside handoff, and 4 (3.9%) responded "never." Two subjects did not respond to this question. As a condition of the survey, the 4 participants who selected "never" as the frequency of experiencing the handoff did not respond to the remaining survey items.
Participants were notably positive about the RN bedside handoff process. Mean scores about the process ranged from 3.0 (SD = 0.730) to 3.45 (SD = 0.638) on the scale of 1 (strongly disagree) to 4 (strongly agree). The overall mean for the 8 items was 3.32 (Table).
The more exposure patients had to the RN bedside handoff, the more positive they were about the process. Correlations between "always" encountering bedside handoff and each survey item ranged from 0.242 to 0.541 (P = .000-.017) Conversely, correlations between "rarely" experiencing bedside handoff and each survey item were generally negative, ranging from r = -0.309 to r = -0.488 (P = .000-.005).
There was one exception to the negative correlations with the frequency "rarely"; the correlation between that frequency and the perception that the RN was planning ahead to meet patients' needs was positive and significant (r = 0.443, P < .001). Even when bedside handoff was rarely experienced, patients perceived that the RN was planning ahead to meet their needs.
DISCUSSION
While existing literature has reported various perceived benefits of bedside handoffs, to our knowledge, this is one of the first to quantitatively measure patients' perceptions in light of their reported exposure to the bedside handoff. The finding of significant correlations between the frequency of bedside handoff and safety, understanding of care, and satisfaction was striking and support the findings of a recently published qualitative study.14 The lack of correlation between "most of the time" and the survey items, and the negative correlations between "rarely" and the survey items, make it difficult to justify a decision not to perform bedside RN handoff all of the time. The results suggest that RN bedside handoff has a positive effect on patients' perceptions of safety, understanding, and satisfaction but only when it is done consistently.
Because they had been working diligently to sustain this change in practice, nursing leaders were initially encouraged to find that 94% of the respondents had experienced bedside handoffs to some degree. However, when it was revealed that only 63% of patients had "always" experienced bedside handoff, the organization's leaders recognized improvements were needed. This finding is consistent with reports that there is often regression to former practices after implementing bedside RN handoff.20,26 This underscores the necessity of ensuring that this practice becomes a new habit and that measures are in place to generate sustainability.
This work corroborates qualitative studies5,6,12,17,18 and quantitative studies, including those using proprietary satisfaction surveys as proxy measures,5,7-9,18 which indicate that bedside RN handoff leads to patient satisfaction. This is one of the first studies, however, to employ quantitative means to assess the level of patient satisfaction with the way information about their care was communicated to the next RN during bedside handoff. The findings indicate that there is a relationship between frequency of bedside handoff and patients' satisfaction with the process.
Participants who consistently experienced bedside RN handoff perceived that the process helped to protect them from errors and mistakes, and that nurses are planning for their care during the handoff. Those patients who reported that they "always" experienced bedside handoff also indicated that they were informed of their care plans in a manner they could understand and were involved in their care.
Limitations and recommendations for future research
The study has several limitations including an extended time frame for data collection due to attrition of research assistants. Because a nonrandomized convenience sample from a single institution was used, there was risk of selection bias and limitation of generalizability.
The survey instrument was evaluated for face and content validity by expert reviewers, and Cronbach [alpha] ([alpha] = 0.92) indicated that there was reliability for the instrument. However, no psychometric evaluation of the instrument was carried out prior to its use.
Future research should be directed at further evaluating the validity of the instrument. Other studies might be directed at family members' perceptions of the bedside handoff process, evaluation of the process at multiple institutions, and in different patient populations or different handoff situations, such as transfers from critical care to general care.
IMPLICATIONS AND RECOMMENDATIONS FOR PRACTICE
Because the research demonstrates the positive effects of RN bedside handoff on patients' perceptions of safety, understanding of care, and satisfaction when it is done consistently, nurse leaders and staff nurses should create a "culture of always" with this process. With the realization that only 63% of patients who completed the survey had reported that they "always" experienced RN bedside handoff, the nursing leaders at our medical center understood there was more work to do. They identified that previous attempts to normalize RN bedside handoff lacked measures of success and failed to achieve the alignment, acceptance, and accountability of staff RNs that are necessary to sustain change.27 The nursing leaders developed an action plan to create a culture of always and maximize the benefits of bedside handoff.
The original research in our setting provided a unique platform on which to build an action plan. Therefore, an early approach was the dissemination of these research results to staff nurses on 5 different nursing units to highlight the magnitude of their role in having a positive impact on patient perceptions through consistent bedside handoff. The nursing leaders also implemented traditional improvement strategies such as reeducation, quizzes, policy review, laminated name badge reference cards, asking patients about bedside handoff frequency during leadership rounds, and enhanced nursing orientation.
There were 4 innovative strategies used to improve performance. One strategy was a series of "flash mob" style observations in which as many as 8 nursing leaders from various departments arrived unannounced to carry out direct observation of competency and "just in time" coaching using the Bedside Handoff Competency Audit (Supplemental Digital Content, Figure, available at http://links.lww.com/JNCQ/A71). The leadership collaborated to ensure "flash mobs" occurred at start of morning and night shifts on each of 5 departments within a 3-week time span. The second innovative strategy was role-playing during staff meetings facilitated by leaders using case scenarios that provided lessons for overcoming peer resistance to bedside handoff. In addition, a sustainable mystery shopper program in which individuals unknown to the nursing staff sporadically pose as visitors and assess compliance in the absence of leadership was implemented. The fourth strategy is the future use of shared storytelling to highlight patient comments and good catches made by staff during the handoff process.
In addition, long- and short-term metrics with thresholds were established to monitor success. Short-term metrics include the following: (a) 100% of RNs complete quizzes within 2 months; (b) 100% of RNs complete case scenarios within 6 months; (c) 100% of RNs observed for competency via flash mob twice within a 6-month period; and (d) 95% of patients report experiencing bedside handoff when asked by nurse leaders during daily rounds. Long-term metrics include the following: (a) 95% monthly quality score derived from an audit tool (Supplemental Digital Content, Figure, available at http://links.lww.com/JNCQ/A71); (b) 95% report of compliance from mystery shoppers quarterly; (c) 100% of RNs demonstrate competency in practice annually; (d) HCAHPS nursing communication items in the 90th percentile; and (e) 90% of patients report a frequency of "always" experiencing bedside handoff in study replication.
CONCLUSIONS
While existing qualitative literature has reported various perceived benefits of bedside handoffs, in this quantitative study patients identified benefits in light of their reported frequency of the handoff. The findings demonstrate that RN bedside handoff has a positive impact on patients' perceptions of safety, understanding, and satisfaction, but only when it is done consistently. While the high percentage of patients who reported experiencing bedside handoff is encouraging, the findings from this study underscore the importance of sustaining organizational nursing practice change. The positive responses to statements about patients' perception of safety, understanding of care, and satisfaction provide evidence to support the involvement of patients in their hospital care through bedside handoffs. Leadership and staff need to work collaboratively to ensure a "culture of always" in this process to achieve maximum benefit for patients.
REFERENCES