DR JENNIFER OROURKE (Orcid ID : 0000-0002-0843-1177)

Article type : Original Research: Empirical research - mixed methods

Accepted Article
A Delphi Study to Identify the Core Components of Nurse to Nurse Handoff

Author Names and Affiliations:

Jennifer O’ROURKE, PhD, RN, APRN

Associate Dean of Graduate Nursing Programs

Loyola University Chicago, Marcella Niehoff School of Nursing

Joanna ABRAHAM, PhD

Assistant Professor, Biomedical and Health Information Sciences

University of Illinois at Chicago

Lee Ann RIESENBERG, PhD, RN

Professor, Department of Anesthesiology and Perioperative Medicine

University of Alabama at Birmingham

Jeff MATSON, MSN, RN, APRN

Graduate Student

University of Illinois at Chicago

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jan.13565
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 Karen DUNN LOPEZ, PhD, RN

Assistant Professor, Department of Health Systems Science

Accepted Article
University of Illinois at Chicago

Corresponding Author:

Jennifer O’ROURKE

Jorourke1@luc.edu

Twitter: JennyORourke7

Loyola University Chicago Marcella Niehoff School of Nursing

2160 S. First Avenue,

Maywood, IL 60153, USA

Funding:This research received no specific grant from any funding agency in the public, commercial,
or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors

ABSTRACT

Aim: To identify the core components of nurse-nurse handoffs.

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 Background: Patient handoffs involve a process of passing information, responsibility and

control from one caregiver to the next during care transitions. Around the globe, ineffective
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handoffs have serious consequences resulting in wrong treatments, delays in diagnosis,

longer stays, medication errors, patient falls and patient deaths. To date, the core components

of nurse-nurse handoff have not been identified. This lack of identification is a significant

gap in moving towards a standardized approach for nurse-nurse handoff.

Design: Mixed methods design using the Delphi technique

Methods: From May 2016 - October 2016, using a series of iterative steps, a panel of

handoff experts gave feedback on the nurse-nurse handoff core components and the content

in each component to be passed from one nurse to the next during a typical unit-based shift

handoff. Consensus was defined as 80% agreement or higher.

Results/Findings: After three rounds of participant review, 17 handoff experts with

backgrounds in clinical nursing practice, academia and handoff research, came to consensus

on the core components of handoff: patient summary, action plan and nurse-nurse synthesis.

Conclusion: This is the first study to identify the core components of nurse-nurse handoff.

Subsequent testing of the core components will involve evaluating the handoff approach in a

simulated and then actual patient care environment. Our long-term goal is to improve patient

safety outcomes by validating an evidence-based handoff framework and handoff curriculum

for pre-licensure nursing programs that strengthens the quality of their handoff

communication as they enter clinical practice.

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 Keywords: handoff, handover, communication, nurses, Delphi technique
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SUMMARY STATEMENT

Why is this research needed?

Ineffective nurse-nurse handoff communication is a global safety threat, yet there is a lack of

empirical evidence that identifies the core components of a typical nurse-nurse handoff.

 Ineffective handoffs can have serious consequences resulting in wrong treatments,

delays in diagnosis, longer stays, medication errors, patient falls and patient deaths.

 This is the first study to identify the core components of nurse-nurse handoff.

What are the key findings?

A typical nurse-nurse handoff includes the core components of patient summary, action plan

and nurse-nurse synthesis.

 Patient summary, defined as the summary of the patient and the situation, includes the

handoff of key patient information including 15 pertinent data areas.

 Action plan, defined as the priority to do list for the incoming nurse, includes the

nursing interventions to implement and monitor.

 Nurse-nurse synthesis, defined as the summary of the patient handoff, may be difficult

to evaluate but is a necessary component of effective handoff.

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 How should the findings be used to influence policy/practice/research/education?

Internationally, leading healthcare organizations recommend standardized handoff

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communication approaches, however no consistency in adoption exists.

 Understanding the core components of nurse-nurse handoff is an important first step

in developing an evidenced based approach to nurse-nurse handoff standardization.

 Training nursing students with a standardized handoff approach could lead to

adoption of these same approaches in the larger healthcare system.

INTRODUCTION

Patient handoffs involve a process of passing information, responsibility and control

from one caregiver to the next during care transitions (Abraham, Nguyen, Almoosa, Patel, &

Patel, 2011; Johnson & Arora, 2016; The Joint Commission (TJC), 2012). Across the globe,

handoffs between nurses are a common hospital process that help to ensure effective and

continuous care delivery and management across the care continuum (Maxson, Derby,

Wrobleski, & Foss, 2012). It is estimated that over 300 million handoffs occur annually in the

United States, more than 100 million in England and more than 40 million in Australia

(American Hospital Association, 2014; Health & Social Care Information Centre. Hospital

Episode Statistics, Admitted Patient Care 2012-2013; Organisation for Economic Co-

Operation and Development, 2011). Optimizing the effectiveness of handoff could have a

major impact on care quality and safety for hospitalized patients.

However, the dynamic, uncertain and complex nature of the care processes in hospital

settings may interfere with the effectiveness of nurse handoffs (Carroll, Williams, &

Gallivan, 2012; Koch et al., 2012; Riesenberg, Leisch, & Cunningham, 2010), leading to

handoff breakdowns (Siemsen et al., 2012; Younan & Franlic, 2013). Nurse handoffs are

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 particularly challenged by variation in documentation of handoff communication, lack of a

centralized view of care in electronic health records and rare interdisciplinary communication
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(Keenan, Yakel, Lopez, Tschannen, & Ford, 2013).

Ineffective handoff communication is far too common, occurring at a rate of 19.8% to

31% depending on the definition, type and assessment or the errors measured during handoffs

(Drach-Zahavy, & Hadid, 2015; Sheth et al., 2016; Thomas, Schultz, Hannaford, &

Runciman, 2013). Ineffective handoffs can have serious consequences resulting in wrong

treatments, delays in diagnosis, longer stays, medication errors, patient falls and patient

deaths (Freitag, & Carroll, 2011; Staggers, & Blaz, 2013; Starmer et al., 2014b). From a

European Commission project, it was estimated that 25-40% of adverse events are due to

handover communication failure (Eggins & Slade, 2015). In a U.S. hospital survey of

160,000 employees, 51% responded that important patient care information is often lost

during shift change, a persistent problem that has not improved (Sorra, Famolaro, Yount,

Smith, Wilson, & Liu, 2014).

Acting on evidence that patient handoffs could be improved if processes were

standardized, a large U.S. accrediting body, The Joint Commission (TJC), mandated that

patient handoffs be standardized as part of U.S. hospital accreditation (2012). This mandate

has led to other patient safety organizations including the World Health Organization

(WHO), Agency for Healthcare Research and Quality (AHRQ), the American Association of

Colleges of Nursing (AACN) and the Quality and Safety Education for Nurses (QSEN),

recommending standardized approaches (e.g., using mnemonics, templates or communication

tools) to communicate handoff content (AACN, 2006; AHRQ, 2016). Despite agreement that

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 formal and standardized content for nurse handoff practice is necessary, we currently lack

empirical evidence that identifies the required core components of a nurse-nurse handoff
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(Abraham et al., 2016; Nasarwanji, Badir, & Gurses, 2016). Without this knowledge, there is

a gap in the validity of currently used handoff approaches for nurse-nurse handoffs (Mardis et

al., 2015).

As an initial step towards the development of a standardized handoff framework

tailored specifically for nurses, we conducted a study to identify the core components of

nurse-nurse handoffs. It was our intention to define the minimum content necessary to be

passed during nurse-nurse shift change handoff, with the assumption that setting- or

population-specific elements could be integrated in to provide a flexible standardization of

content. This handoff framework could then be tested and ultimately uniformly applied

across other all nurse-nurse handoffs, such as unit to unit (Abraham et al., 2017; Staggers &

Blaz, 2013).

BACKGROUND

Barriers to Effective Handoffs

Researchers investigating nurse handoffs have identified gaps in information transfer

(Siemsen et al., 2012) and in communication (Abraham, Kannampallil, & Patel, 2012; Carroll

et al., 2012), resulting from inadequate and dysfunctional health information technologies

(Vawdrey, Stein, Fred, Bostwick & Stetson, 2013) and nurse handoff tools. Too little or too

much information share, frequent interruptions and having limited time to ask questions have

also been identified as barriers (Young, ten Cate, O’Sullivan, & Irby, 2016). Nurses may

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 have varying information and communication expectations during handoffs, with preferences

for eye contact and the ability to ask questions and give report with no interruptions (Carroll
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et al., 2012).

Complying with Regulatory Handoff Standard

With little or no evidence-based effective handoff approaches, many hospitals and

healthcare organizations around the globe have standardized approaches to handoffs by

creating or borrowing handoff approaches from other industries and implementing these

frameworks (Holly & Poletick, 2014). Most efforts to mitigate nurse handoff barriers focused

on incorporating structure into nurse-nurse information transfer and communication

processes (Kear, 2016; Riesenberg et al., 2010; Vawdrey at al., 2013). At least 24, handoff

approaches, supported by mnemonics to standardize verbal communication, have been

implemented and used (Abraham et al., 2012; Riesenberg, Leitzsch, & Little, 2009). Handoff

mnemonics serve as cognitive aids and have been shown to reduce content omissions

(Riesenberg, et al., 2009; Weiss, Bhanji, Fontela, & Razack, 2013).

Some examples include I PASS THE BATON (Introduction, Patient, Assessment,

Situation, Safety concerns, Background, Actions, Timing, Ownership and Next), (American

College of Obstetricians and Gynaecologists, 2012), ISBAR (Introduction, Situation,

Background, Assessment and Recommendation), (Thompson et al., 2011), P-VITAL

(Presenting Information, Vital signs, Input and output, Treatments, Admission or discharge

criteria and Legal documents), (Wilson, 2011), Five Ps (Option 1-Patient Plan, Purpose of

plan, Problem, Precaution; Option 2-Patient, Precautions, Plan of care, Problem, Purpose),

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 (Runy, 2008), PACE (Patient/problem, Assessment/actions, Continuing/changes and

Evaluation) (Schroeder, 2006) and SBAR (Situation, Background, Assessment and

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Recommendation) (Martin & Ciurzynski, 2015).

Of these various mnemonics, the most cited is SBAR (Riesenberg et al., 2010).

However, SBAR has significant limitations for nurse-nurse handoff. SBAR was first used in

healthcare as a way for nurses to communicate a change in a patient’s situation to physicians

(Institute for Healthcare Improvement, 2008; Leonard at al., 2004). It has since been

recommended as a structured way for nurses to communicate routine nurse-nurse handoffs

(Blom, Peterson, Hagell, & Westergren, 2015; Randmaa, Swenne, Martensson, Higberg &

Engstrom, 2016). It is important to note that SBAR was not designed to provide a

comprehensive nurse-nurse handoff of pertinent patient care information needed to transfer

care. To use SBAR in such a way requires modifications across units and situations.

Furthermore, despite widespread use, SBAR has not been validated as an effective and

efficient nurse-nurse handoff mnemonic (Holly & Poletick, 2014; Malone anderson, &

Manning, 2016; Riesenberg et al., 2010; Staggers & Blaz, 2013).

Evidence Based Handoff Framework

A physician-physician handoff tool that has demonstrated a significant reduction in

medical errors is the I-PASS mnemonic (Illness severity, Patient summary, Action list,

Situation awareness and contingency planning, Synthesis by receiver) (Starmer et al., 2012a;

Starmer et al., 2014a). In one study, where I-PASS was implemented across 9 U.S. hospitals,

outcome data revealed a statistically significant drop in adverse events by 30% (Starmer et

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 al., 2014a). I-PASS has been adopted and integrated in some leading electronic health record

(EHR) vendor systems to support unit-based physician handoffs (Starmer et al., 2014a;
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Starmer et al., 2014b) and there is a push towards adapting the approach to other types of

handoffs including nursing.

Although the core components of the I-PASS approach have not yet been validated

for use in nurse-nurse handoffs, we sought to adapt the validated I-PASS and develop a

companion approach for nursing. Complimentary nursing and physician handoff frameworks

provide a more effective method for developing training, evaluation of handoffs and for

interprofessional collaboration. Therefore, we sought to identify the core components and

component content of nurse-nurse handoff using the Delphi method. The identification of the

core components and content of a nurse-nurse handoff can potentially inform the

development of an empirically based handoff framework and curriculum for training and

educating nursing students and the workforce.

THE STUDY

Aim

The aim of this study was to identify the core components of nurse-nurse handoff.

Design

A mixed methods design using the Delphi method was used to identify the core

components and content of nurse-nurse handoff. The Delphi method, originally developed in

the 1960’s, involves an iterative process of review by experts that is designed to reach

consensus (Dalkey, 1969). This method proves useful to address an area that lacks certainty

or empirical evidence. A key strength of the Delphi method is the avoidance of group

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 communication behaviours that may inhibit creativity and independent thinking. Both

qualitative and quantitative data was collected using Google Forms in sequential rounds with
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preliminary findings and feedback from the previous round integrated into the subsequent

round. All data were collected between May 2016 and October 2016.

Data collection involved a series of questions posed to study participants to evaluate the

conceptualized core nurse-nurse handoff components of Illness Severity, Patient Summary,

Action Plan and Synthesis by Receiver and the key content under each core component that

were essential to include when handing off patient information. Both the core components

and content under each, were developed using I-PASS as a guide, coupled with an extensive

literature review of other handoff tools including: I-PASS-THE-BATON, P-VITAL and

PACE. All of these tools include core components to handoff, such as Illness Severity and

Patient Summary for the I-PASS, as well as content under each, such as summary statement,

assessment and hospital course which are included under Patient Summary for the I-PASS.

Of note, one component of the medical I-PASS, situation awareness/contingency

planning was not included in conceptualization of our nurse-nurse handoff. This modification

was made based on the review of nursing handoff literature and reflection of the project goal,

which was to create a nurse-centric approach. Rather than include situation

awareness/contingency planning as a distinct step in handoff, we incorporated it into Patient

Summary and Action Plan.

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 Participants

Consistent with Powell’s (2003) synthesis approach to the Delphi method, we sought
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diversity of viewpoints by identifying several types of participants to serve as expert panel

members. This included international authors of nursing handoff studies in peer reviewed

manuscripts from academia and practice, clinical nurse leaders, nursing faculty and a medical

education handoff expert. Our goal was to recruit an equal sample of practicing nurse

clinicians, who worked day-to-day teaching and using handoff and handoff researchers. In

total, 23 individuals were contacted for inclusion in the study.

Data Collection

In round 1, study participants were introduced to the study objectives and provided some

assumptions. Participants were encouraged to think about core nurse-nurse handoff

components (proposed as Illness Severity, Patient Summary, Action List, Synthesis by

Receiver) and the content under each of these four areas (proposed as the specific patient data

categories and tasks in each component) that should be passed from one nurse to the next

during a typical unit-based shift handoff. It was stressed to the participants that additional

unit specific or patient population specific areas might be added to this list but our primary

interest were the core components and content that could be applied across hospitalized

patients. Participants were asked to reserve comments regarding the delivery of the

components (verbal, electronic medical record, paper, etc.) and instead focus on the core

components.

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 Participants were provided the initial conceptualized components of nurse-nurse handoff,

Illness Severity, Patient Summary, Action List and Synthesis by Receiver and asked to rate
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the importance of each component on a 4-point Likert type scale (not at all important,

somewhat not important, somewhat important, highly important). Open-ended questions

followed to determine the rationale for responses and areas for additional modifications or

additions. Under each of the four components, participants were then asked to rate the

relevancy of the content that fell under each core component (not at all relevant, somewhat

not relevant, somewhat relevant, highly relevant) and provide a rationale for their response.

Figure 1 depicts the Delphi process used in this study.

Ethical Considerations

Following study approval by Institutional Review Board (IRB), participants were

contacted through email and asked to consent for study participation. All participants selected

an individual participant code that they used throughout the three-phase study to allow for

confidentiality of responses. All participants were blinded to each other, which is

recommended with the Delphi method. Participants who consented received a link to the

Google Form to begin study participation.

Data Analysis

Using a process used by Berg et al. (2013a) and Berg et al. (2013b), both quantitative

items and open-ended qualitative responses were collected to validate date across each Delphi

round. A mixed method approach also assured that follow-up questions about the experts’

rationale for their quantitative responses were accurately capturing the researcher

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 interpretation of the responses from each round. A cut-point of 80% consensus was set for all

quantitative items (Ulschak, 1983).

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All quantitative scores, those above and below the 80% cut-point were examined and

compared with the qualitative data to validate responses and determine the need for

modifications in subsequent rounds. Qualitative responses were grouped using content

analysis methods (Hsieh & Shannon, 2005). In each round, when there was a discrepancy

between any quantitative rating and the matching qualitative response, the question was

presented back to the expert participants in the subsequent round to fully understand the

inconsistency. For example, this was often presented back by asking a question such as, “in

round 1 we proposed X and based on your feedback we would like you to consider the

following two alternatives.” Findings from each round were used to determine additions and

modifications in the core components and content in subsequent rounds.

Consensus across all items was determined by quantifying the total percent (%) of

responses that included the two positive indicators of importance (somewhat important,

highly important) and relevance (somewhat relevant, highly relevant). Data collection ceased

when a greater than 80% final percent score was met for each core component and the

qualitative responses matched with those scores.

Study Rigour

Assuring methodological rigour using Delphi methods is a challenge (Hasson &

Keeney, 2011); however, we used several methods to establish rigour for both quantitative

and qualitative inquiry. To ensure confidentiality of responses, all participants used a self-

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 assigned anonymous code across the three-step data collection process and all participants

were blinded to each other. To strengthen validity, both quantitative and qualitative data were
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used, as recommended for a modified Delphi process (Hsu & Sandford, 2007). The findings

were fed back to the participants after each round to increase the likelihood that the results

reflected group consensus and were credible (Okoli & Pawlowski, 2004). To ensure

reliability and dependability, a sample of both practicing nurses and handoff experts were

included (Cornick, 2006). Detailed notes of the data collection and evaluation process were

also kept (Skulmoski, Hartman, & Krahn, 2007).

RESULTS

Participants

Of the 23 total individuals initially contacted to participate in the study, 17 (74%)

consented to participate in the study and completed round 1. Sixteen (94%) completed round

2 and 15 (88%) completed round 3. Ninety-four percent of participants were female (n = 16)

and the average age of participants was 42 years old. Thirty-five percent (n = 6) had a

doctoral degree (including doctor of philosophy (PhD), doctor of nursing practice (DNP) and

a doctor of informatics), 1 was an medical doctor (MD), the other 59% held a master’s or

bachelors in nursing. Ten of the participants identified themselves as active clinicians, using

and/or teaching handoff on a regular basis to nurses and nursing students.

Round 1 Results

Overall 82% of the participants felt that the four components of the nurse-nurse

framework (as a unit) were important in nurse-nurse handoffs; Illness Severity (94%), Patient

Summary (100%), Action List (100%), Synthesis by Receiver (94%) (Table 1). However,

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 specific feedback on each of the components and the content under each component revealed

areas for modification.

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Illness Severity, initially defined as the patient acuity level, received a high

importance score (94%) (Table 2); however, qualitative responses revealed a major concern

that the term and definition were not clear and did not reflect a nursing mode. For example,

several participants commented that severity and acuity were vague and difficult to define.

Other participants commented that “illness severity is not as important because a receiving

nurse could ascertain the severity based on the patient summary” and that “patient acuity

definitions can differ” depending on the rubric that is used. Others commented that nursing

handoff literature did not include Illness Severity as a primary component of nurse-nurse

handoff as it was perceived as a subjective measure that each nurse could potentially

determine themselves. Initially, Illness Severity was conceptualized as including the content

categories of Stable, Unstable, Guarded and Undetermined, but only Stable and Unstable met

the 80% consensus for relevancy. Participant comments about Undetermined and Guarded

were largely based on the vagueness and changing nature of a patient status that would be

“less than helpful” for a nurse to categorize a patient as.

Patient Summary, defined as the summary of the patient and the situation, received a

high importance score (100%) (Table 3). Qualitative responses indicated that Patient

Summary is potentially the most important of the four components because it “paints a

picture of the patient situation.” One-hundred percent of participants felt the proposed

definition was a fit. Thirteen content areas under Patient Summary all scored above 80% for

relevancy except for Nursing Diagnosis (59%). Several participants commented on the need

to maintain a list of content areas under Patient Summary, with one participant stating that the

content areas “may not apply to every patient, but they should be included in a standard

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 handoff to make sure they are never missed when there is applicable data.” Participants

recommended incorporating additional content areas under this component including

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ambulatory status and activities of daily living (ADLs).

Action List, defined as the priority to do list for the incoming nurse, received a high

importance score (100%) (Table 4) and 94% felt that the definition adequately captured the

component. Participants commented that Action List should encompass an “ongoing

management plan for the patient” and the nurse as the coordinator of an interprofessional care

team for the patient should convey “more than just actions” during handoff. The four content

areas under Action List including, Nursing Interventions to Consider, Procedures/tests to do,

Discharge Planning and Nursing interventions to Monitor, scored over 80% for relevancy.

Qualitative responses indicated the need to consider other areas to add here that “might not be

communicated in the patient record but that should be communicated” between nurses, so as

not to lose sight of patient centred aspects of care delivery and management, including patient

education. Several participants commented on the link between Action Plan content areas and

a Nursing Care Plan which can capture “… more than …. to do.”

Synthesis by Receiver, defined as the summary of what the incoming nurse heard, had

an importance score of 94% but only 75% felt the definition was a fit. Qualitative responses

reflected a consistent need to revise this category (Table 5). For example, one participant

commented that this could be interpreted as a “lengthy read back” and that “summary” may

be a better term. Synthesis by Receiver was conceptualized as including the two content areas

of did receiver summarize what they heard correctly and did receiver restate priority actions

but many participants commented that these were not fit as “summarizing back” makes it

sound like something that is only done at the end and not throughout the entire handoff

process. Another participant commented that “restating the major concerns” may be sufficient

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 rather than a lengthy recite, especially when the incoming nurse is familiar with the patient

they are receiving handoff on.

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Round 2 Results

As described in the methods section, the core handoff components and corresponding

content under each were revised and presented back to the experts for review in round 2.

Based on the discrepancy between the quantitative importance of Illness Severity (94%) and

the qualitative feedback, in round 2 we asked participants if Illness Severity, could be better

captured using terms like, Patient Status, or Nursing Care Complexity. Eighty-one percent

indicated that Patient Status was a better fit. However, qualitative responses reflected a

continued concern that this core component was difficult to define and “no standards are

available to objectively define complexity, acuity or status.” Several participants stated that

these terms were subjective and that a novice nurse and an experienced nurse could

potentially judge patient status very differently. Based on round 2 responses and after a

rigorous discussion by the research team, this component was removed from nurse-nurse

handoff core components.

In round 1, there was a high association between the quantitative and qualitative

responses for Patient Summary. Based on the opinions of the exerts, three additional content

areas, ambulatory status, activities of daily living (ADLs) and lines/drains/tubes were added

to Patient Summary in round 2. All three content areas were rated at 100% for importance

and no. additional Patient Summary content areas were suggested. However, several

participants commented on the use of the term “pertinent” as a subjective term. The research

team discussed this feedback but determined that using terms like “pertinent medical history”

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 would allow for flexible standardization of content depending on if the patient was familiar or

unfamiliar to the reporting and receiving nurse.

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There was a high association in round 1 between the importance of Action List, as a

core component and qualitative responses. One additional content area, patient education,

was added in round 2 and this was supported with an importance rating of 94%. Based on

feedback received in round 1, in round 2 participants were asked if this core component

should be termed nursing task list or nursing action plan. Nursing task list scored under 80%

for importance and several participants commented that this was individualized and the

outgoing nurses should not “dictate tasks” to the incoming nurse. Participants felt strongly

that action plan was a better fit than nursing action plan because “patient care is done by a

team” not by a nurse.

In round 2, Synthesis by Receiver received a score of 88% as a necessary final

component in nurse-nurse handoff. Four other comparative terms were provided to

participants and they were asked to comment on the fit. None of the other terms, Receiver

summary, Receiver clarification, Report read back and Summary sentence reached a

consensus score. Qualitative responses reiterated the need for the nurse synthesis of the

handoff information exchanged to be “flexible”, rather than a mandatory component with

specific required elements. The recommendation was made to change the term to nurse-nurse

synthesis to be more consistent with a two-way communication between nurses rather than

just the receiver.

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 Round 3 Results

Based on feedback from the previous two rounds, Illness Severity, in round 3, was
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removed as the first core component of nurse-nurse handoff and instead Patient Summary

was incorporated as the first component. One hundred percent agreed that Illness Severity is

not a primary component of nurse-nurse handoff. Eighty-seven percent of participants agreed

that Patient Summary should be the first component of nurse-nurse handoff. Four participants

made additional comments under Patient Summary; however, there was not any consensus

between those comments and on review by the research team, a decision was made that

Patient Summary had met consensus.

Eighty-seven percent agreed with Action Plan as the second component of nurse-

nurse handoff. One participants commented that “nursing” should be removed from “nursing

interventions” however the research team discussed this and determined that in this

circumstance the Action Plan can include more specific nursing specific terms so that the

areas are clear. Based on the cut-point score of 87% and the associated matching qualitative

comments, a decision was made that Action Plan had met consensus.

Eight-seven percent agreed with renaming and defining the third component of nurse-

nurse handoff as Nurse-Nurse Synthesis. A continued area of concern for several participants

was the difficulty of teaching this last step to novice nurses. In addition, one participant

commented that a synthesis “should be occurring throughout” hand-off rather than just at the

end. The research team discussed these comments and determined that a consensus had been

met based on the 87% score and associated qualitative response however a need to explore

these two areas was discussed for future steps with handoff.

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 DISCUSSION
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Standardization of nurse-nurse handoff content can reduce communication failures.

However, there is no simple yet robust way for identifying and developing the core

components to standardize handoffs. The lack of previous research in this area speaks to the

challenge of identifying a consensus in developing an ideal nurse-nurse handoff framework.

Nevertheless, our findings represent a strong first step in moving toward this goal. To

contextualize our framework and its use in nurse-nurse handoffs, we performed two types of

comparisons – (1) with the medical IPASS (given that it was our initial framework) and (2)

with a popular nursing handoff framework, SBAR. These comparisons were performed to

ensure that our framework is leveraging existing frameworks.

In the I-PASS and SBAR approaches, the first component is an identification of

Illness Severity (I-PASS) and the Situation (SBAR). Illness Severity has importance in the I-

PASS approach because it was designed as a physician-physician report on several patients,

therefore the illness severity index is a comparison across those patients (Starmer et al.,

2012). This is not as relevant in nurse-nurse handoff where more often a nurse-nurse handoff

involves handing off patients to multiple incoming nurses, depending on assignment.

Although we initially conceptualized Illness Severity as our first component, our results

confirm that this term and related terms are not fully supported in nursing because of the

subjective nature of these components and the difficulty in qualifying patient severity or

nursing care complexity. In addition, a patient could be medically stable but have complex

nursing care needs. The situation, for SBAR, is a concise statement of the problem (Leonard

et al., 2004). While this may be an important first statement for an urgent communication

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 between a nurse and physician, it is not relevant for a routine nurse-nurse handoff at change

of shift.
Accepted Article
We conceptualized Patient Summary as the first core component of our nurse-nurse

handoff framework. Both I-PASS and SBAR include a similar patient summary as part of

their approach. In our framework, the summary is meant to be pertinent data to inform the

provision of nursing care and unlike the SBAR, we identified the relevant elements that

should be included under this component. We also included patient assessment in our patient

summary unlike SBAR which identifies this as a separate component. The I-PASS patient

summary is meant to be an overall summary of the hospitalization history and medical plan

but this is not helpful in delineating the specific information that a nurse needs to know to

promote patient safety and provide nursing care. Based on a review of the literature and as

tested in this study, we identified 15 content areas that were important to include in a nurse-

nurse handoff.

Our second core component is Action Plan. Although similar to the I-PASS approach,

it is more specific to nursing, patient education and the care coordination that are essential to

pass from shift to shift because often these are the data that are easily lost in a nursing note

(Pothier et al., 2005). The last component of SBAR, recommendation, is the action that the

nurse is requesting or recommending. Action Plan component is more comprehensive as it

focuses on a holistic view of the patient needs rather than on one primary urgent need of the

patient, like SBAR.

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 Like the I-PASS, we found that nurse-nurse synthesis, is an important component of

handoff as it allows for both the sender and receiver to ask questions. Our participants
Accepted Article
confirmed that this is a core component of nurse-nurse handoff, but recognized that it may be

hard to evaluate in practice and to teach. This has been confirmed in studies with the I-PASS

(Shahian, McEachern, Rossi, Chisari, & Mort, 2016).

There are several next steps in the validation of the core components of nurse-nurse

handoff identified here, which we have termed N-PAS (Nurse-Patient Summary, Action Plan

and Synthesis). First, the core components need to be evaluated in a simulated setting. Most

existing studies have evaluated handoff outcomes in the inpatient hospital environment which

seems appropriate; however, the chaotic, unstructured and non-standardized environment

poses a challenge for studying nurse handoffs. By first using a simulated environment to test

the nurse-nurse handoff, we can standardize the situation and observe and evaluate handoff

effectiveness and efficiency with a large sample of heterogeneous nurses with varied levels of

experience, across different geographic locations. In addition, any problems that could

potentially have an impact on patient safety and care quality can be identified without

harming actual patients. Once we have evaluated the nurse-nurse handoff approach in a

simulated setting, an evaluation study will be done focusing on assessing the communication

effectiveness of the method in multiple actual hospital settings.

In nursing practice there are a variety of delivery approaches for nurse-nurse handoff

including the use of bedside report, nursing rounds and using paper and EHR documents. As

part of the evaluation of the nurse-nurse handoff, it will also be important to consider handoff

delivery methods. For example, do all the content areas under Patient Summary have to

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 verbally reported during nurse-nurse handoff or can some of these be passed through a

handoff template sheet. Included in the I-PASS approach are templates for communicating
Accepted Article
information which might prove useful as we move the nurse-nurse handoff approach forward.

LIMITATIONS

Despite the well-established strengths of the Delphi technique for identification and

confirmation of concepts, use of this approach may have had certain limitations in this study.

One of the major critiques of the Delphi is assuring methodological rigour which is often

cited as a weakness because there are over 10 different types of Delphi methods (Hasson &

Keeney, 2011). However, there are several recommendations for methods to improve the

rigour that we applied (Keeney, Hasson & McKenna (2011). To improve reliability and

validity, we used a pre-established protocol for data collection and for data evaluation, as

recommended by Powell (2002) and Chia-Chien et al., (2007). Study participants and

researchers were blinded to the identity of the participants which further supports, although

does not assure rigour (Hasson & Keeney, 2011). In addition, we used several methods to

establish trustworthiness including: having panel member checks through their review of the

summary data after each round, using a sample of established handoff experts and practicing

nurses and by keeping meticulous study journal of the process used and the discussion during

each round of data analysis (Cornick, 2006; Okoli & Pawlowski, 2004; Skulmoski et al.,

2007).

We relied on experts to assist with identification of all possible core components and

elements of nurse-nurse handoff but it is possible that our methods failed to capture some

subtle elements that might be better identified through an observational study of nurse

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 handoffs. For example, we were only able to recruit one international study participant who

could not fully represent the diversity of handoff around the globe. Finally, we recognize the
Accepted Article
list of 15 content areas under Patient Summary, likely exceeds working memory capabilities.

Additional structuring of this information may have potential for decreasing the cognitive

burden of this handoff content.

CONCLUSIONS

This is the first study to use the Delphi Method to identify the core components of

nurse-to-nurse handoffs. N-PAS, includes a nurse centric approach with a Patient Summary,

Action Plan and a Nurse-Nurse Synthesis. Results from this study will inform a nurse-nurse

handoff framework and training curriculum. The Accreditation Council for Graduate Medical

Education (ACGME) in the U.S. requires education and training for medical residents to

prepare them to be competent in communication handover (Liston, Tartaglia, Evans, Walker,

& Torre, 2014). To our knowledge, nursing does not have similar requirements in either the

United States or internationally. Insights from this study will enable testing of the approach in

simulated and real clinical situations and lead to the development of a curriculum to teach

and evaluate a standardized approach for nurse-nurse handoff. Our long-term goal is to

improve patient safety outcomes by validating an evidence-based handoff framework and

curriculum for pre-licensure nursing programs that strengthens the quality of their handoff

communication as they enter practice.

Author Contributions:

All authors have agreed on the final version and meet at least one of the following

criteria (recommended by the ICMJE*):

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 1) substantial contributions to conception and design, acquisition of data, or analysis

and interpretation of data;

Accepted Article
2) drafting the article or revising it critically for important intellectual content.

* http://www.icmje.org/recommendations/

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ccepted Articl
Table 1. Proposed Major Components of Handoff and % Agreement

MD IPASS Nurse-Nurse Round 1 Revision 1 Round 2 Revision 2 Round 3 N-PAS (Nurse-Patient

Summary, Action Plan,
Synthesis)
I- Illness Severity Illness 94% -Patient Status 81% Remove 87%
Severity Illness
-Nursing Care 13% Severity
complexity

-Illness 0%
Severity

P-Patient Summary Patient 100% Patient Not asked 87% Patient Summary
Summary Summary
A-Action List Action Plan 100% Action Plan Not asked 87% Action Plan
S-Situation Merged with Patient summary, action plan and synthesis by receiver
Awareness/Contingency
Planning
S-Synthesis by Receiver Synthesis by 94% -Synthesis by 69% Nurse- 87% Nurse-Nurse Synthesis
Receiver Receiver Nurse
Synthesis
-Receiver 56%
summary

-Receiver 44%
clarification

-Report Read 19%

back

-Summary 25%
sentence

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ccepted Articl
Table 2: Illness Severity Definition and Content with % Agreement and Qualitative Results

MD Nurse-Nurse Round 1 Revision 1 Round 2 Revision 2 Round 3 N-PAS

IPASS
Definition Not Patient acuity 94%
defined level
Content -Stable -Stable 88% -Patient Status 81% Remove 87% Not included
Core agreement
-Watcher -Unstable 100% -Nursing Care 13% Component to delete
complexity core
-Unstable -Guarded 76% component
-Illness 0% from
-Undetermined 42% Severity acronym

Major -Acuity is -No accepted

Qualitative vague definition or
Responses scale for
-Illness complexity
severity not or acuity
related to
nursing care -This first
needs area should
communicate
-Undetermined something
is difficult to the incoming
define nurse can
benefit from

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ccepted Articl
Table 3: Patient Summary Definition and Content, with % Agreement and Qualitative Results

Definition
MD IPASS

Not defined
Nurse-Nurse

Summary of the
Round 1

100%
Revision 1 Round
2
Revision
2
Round 3 N-PAS

Summary of the
patient and the patient and the
situation situation
Content -Summary -Demographics 100% Removed: Include 87% Patient 15 Content Areas
Statement Nursing all round agreement Summary -Demographics
-Admitting 94% Diagnosis 2 content to include
-Events Diagnoses categories 15 areas of -Admitting
leading to Added: Patient Diagnoses
admission -Nursing 59% -Lines, drains 94% Summary
Diagnoses & tubes -Mental Status
-Hospital
course -Mental Status 94% -ADL status 94% -Code Status

-Ongoing -Code Status 94% -Ambulatory 94% -Allergies

assessment status
-Allergies 94% -Pertinent Medical
-Plan History
-Pertinent 100%
Medical History -Current Vital Signs

-Current Vital 94% -Current Labs

Signs
-Pertinent physical
-Current Labs 94% assessment

-Pertinent 94% -Pertinent

physical Medications
assessment
-Pertinent Family
-Pertinent 94% Information
Medications
-Precautions
-Pertinent Family 94%

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ccepted Articl Information

-Precautions 100%
-Lines, drains &
tubes

-ADL status

-Ambulatory status

Major -What most -Might

qualitative handoffs want to
responses are about think
-Include about
additional pertinent
areas like
lines,
ADLs

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 Table 4: Action Plan Summary Definition and Content, with % Agreement and Qualitative Results

ccepted Articl MD IPASS Nurse-Nurse Round 1 Revision 1 Round 2 Revision

2
Round 3 N-PAS

Definition Not defined Priority to do list 94% Priority to do list for

for the incoming the incoming nurse
nurse
Content -To do list - Nursing 100% Added: Include 87% Action 5 Content Areas
Interventions to all round agreement Plan
Consider - Patient 94% 2 content to include 5 -Nursing Interventions
education elements areas of to Consider
-Timeline and
ownership Action Plan
- Procedures/tests
to do - Procedures/tests to do
100%

- Discharge - Discharge Planning

Planning
94%
-Nursing interventions
-Nursing to Monitor
interventions to
Monitor
94% -Patient/family
education

Major -Guides the -Patient

qualitative next nurse and
responses family
education
-Consider
other areas
that “might
not be
communicated
in the patient

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ccepted Articl record” but
that are
important

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ccepted Articl
Table 5: Synthesis by Receiver Definition and Content, with % Agreement and Qualitative Results

MD IPASS Nurse-Nurse Round 1 Revision 1 Round 2 Revision Round 3 N-PAS

2
Definition Not defined Summary of 75% The handoff report
what the as synthesized by the
incoming nurse incoming nurse
heard
Content -Receiver -Did receiver 94% Removed: Change to 87% Nurse-
summarizes summarize what -Did receiver 88% Nurse- agreement Nurse
what was heard they heard summarize Nurse to make Synthesis
-Asks correctly what they Synthesis core
questions heard component
-Restates key -Did receiver 94% correctly nurse-nurse
action/to do restate priority synthesis
items actions -Did receiver 88%
restate
priority
actions

Major -Not a Receiver

qualitative lengthy synthesis
responses read back depends
on
-Summary receiver
better term

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 Figure 1. Study Methods
Accepted Article
Round 1 Survey

Distributed quantitative and open-ended items to panelists

Quantitative Qualitative
data reviewed data reviewed

Comparison of
findings

Summary of results
determined by researcher
consensus across all items

Items not meeting 80%

benchmark revised and
sent back to panelists

Round 2 Survey

Process repeated

Round 3 Survey

Process repeated

All items met 80%

benchmark

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