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Running head: ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 1
Adapting SBAR Handoff to Simplify the Patient's Story: A Process Improvement Project
Marie Wendt
MidMichigan Health
Author Affiliation: Marie Wendt is the Nurse Manager Surgical Intensive Care Unit at
MidMichigan Health, Midland, Michigan, USA
Correspondence: Marie M. Wendt, BSN, RN, MidMichigan Health, 4000 Wellness Drive,
Midland, MI, 48670. (E-mail: [email protected]) Phone: 989-839-1579
Conflict of interest statement: The author declares there are conflicts of interest.
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 2
Abstract
Standardized handoff processes in healthcare have demonstrated increases in registered nurse
(RN) collaboration and patient safety. Despite this, uncoordinated handoffs continue to occur in
critical care settings, jeopardizing patient safety and negatively impacting nurse satisfaction. By
employing Lewin’s Change Theory of unfreezing, moving, and refreezing, a performance
improvement project for developing and initiating an evidence based standardized Situation,
Background, Assessment, Recommendation (SBAR) handoff tool was piloted for a period of
four weeks. The project lead demonstrated Relationship Based Care and Transformational
Leadership styles of behavior during the Plan-Do-Study-Act cycle method for process
improvement. The introduction of a modified SBAR paper tool demonstrated that when utilized
to its full capacity there was an improvement in nurse satisfaction in knowing the patients story.
Key words: Handoff(s), Shift Report, Nurses Report, Handoff Communication, Standardized
Report.
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 3
Accurate shift to shift handoff is essential for safe patient care. For critical care
registered nurses (RNs), it is vital to understand the patient’s story to safely care for them.
Patient handoff is significant in critical care units where nurses are accountable for two seriously
ill patients simultaneously.1 When nurses work 12 hour shifts, there can be a lack of continuity of
care from day to day. It is important to have a consistent method to relay the original information
from the date of admission throughout the patient’s length of stay. Using evidence based
practice (EBP), a Situation, Background, Assessment Recommendation (SBAR) report tool was
created and implemented at shift-to-shift handoff in a neuro trauma intensive care unit (NTICU),
in an effort to improve the RNs knowledge of the patient’s overall story prior to beginning
patient care.
Support for Improvement
The Joint Commission (JC) defines handoff as “the transfer and acceptance of patient
care responsibility achieved through effective communication.”2 According the JC,
miscommunications during collaboration between care givers accounts for 66% of errors in
healthcare.3 The Agency for Healthcare Research & Quality (AHRQ) published that 49% of
survey respondents in one study, stated that information is omitted during shift to shift
changeover.4 In an effort to impact this safety concern, the JC included nurse collaboration in its
2007 National Patient Safety Goals.5 The National Patient Safety Goal (NPSG) included a
formalized process for handoff where nurses to have time to ask questions during the handoff.
Despite this NPSG, governing agencies have not recommended one consistent method of
handoff for ensuring patient safety. Adding to this challenge, there is minimal evidence to
support any one single method.6 Nonetheless, there are strong recommendations in healthcare to
formalize the handoff process.7 Standardized checklists is one strategy. By incorporating
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 4
standardized checklists, one study demonstrated a decrease in complication rates in 6 hospitals
from 27% to 17%.8 Studies such as this demonstrate the need for critical care nurses to adopt a
method which incorporates various evidenced based best practice reasoning into their own
handoff procedure.
There are many barriers to performing an appropriate, safe, and meaningful handoff at
change of shift. These barriers include but are not all inclusive; lack of standardization, lack of
policy related to handoff, staff resistance, lack of research data to support best practices, time
constraints, an increase in the complexity of care, inadequate training, and department cultural
norms.9 A further look at the barriers specific to NTICU’s handoff process will be looked at later
in this article. It is important to understand and address any barriers when attempting to
improve processes.
Plan Stage (Phase)
The EBP standardized SBAR method for handoff has been demonstrated to decrease
errors with nursing practice. In 2010, Mission Hospital in Mission Viejo California, reported 750
near misses being thwarted by the use of instituting standardized tools such as SBAR for handoff
communication in a six month time period.10 Stevens goes on to report that pharmacy related
errors decreased from 18% to 2% in 2010.11 Other research demonstrates the amount of patient
information omissions decreasing from a mean of 4.96% to 2.29% per handoff, with a result of
home medication issue error rates decreasing from 38% to 9%.12 Additionally, this study
exhibited a decrease lack of RN knowledge related to abnormal laboratory findings from 90% to
48%.13 Evidence indicates being thoroughly organized with information sharing at handoff is
critical.14 The SBAR approach provides such methodology. This method has also demonstrated
to be an effective means for healthcare providers in acute and non-acute care settings.15 The
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 5
commonly used SBAR practice is known for assisting to decrease inaccurate and unstructured
handoffs in healthcare.16 Therefore, an SBAR approach was adopted for the project.
The NTICU Shift to Shift RN Handoff Performance Improvement Project set out to
implement a safe consistent method for relaying pertinent information between RNs working
opposite shifts. The NTICU was chosen for the project for its long lengths of stays related to
multiple traumatic injuries. These characteristics add to the complexity of relaying each
patient’s and family’s story. The NTICU RNs stated that they wanted to improve patient safety
and collaboration, voicing concerns of not having a full understanding of the patient’s overall
story.
Well thought out designing during the planning stage of the performance improvement
project is the foundation of its success. In preparation for the Shift to Shift Handoff Project, a
project template was designed with timelines, goals, and objectives. The project template was
utilized as a guide for keeping the project moving forward. The Plan Do Study Act (PDSA)
method was utilized for project completion. According to the AHRQ, the PDSA cycle is an
uncomplicated method to fast track process improvement.17 In an effort to obtain peak buy in
from the staff RNs, the NTICU nurse manager was queried for those staff that were strong
advocates for process improvement or passionate about improving the shift to shift handoff
process. The project lead also emailed all NTICU RNs to elicit enthusiasm and volunteers. Both
of these methods resulted in 2 team members formally joining the project. One from each shift.
The project team performed a root cause analysis (RCA) to determine the department’s barriers
to performing a consistent comprehensive shift to shift RN handoff. The results concluded that
the neuro trauma intensive care unit’s barriers were similar to the barriers published in EBP.
These included recent changes in patient acuity, concerns with electronic medical record (EMR),
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 6
lack of tool consistency, time constraints, nurse experience or training and cultural pressures
between staff.18 Specific conclusions ascertained from NTICU’s RCA were concerns with
process, tools, communication, time constraints, technology, environment, education, and staff
culture. Process included inconsistent practices from the various RNs having no policy to direct
them. Tools involved not having a single consistent method that is evidence based.
Communication discovered omissions and inaccuracies in information being shared. Time
constraints pointed towards staff concerns of bedside handoff taking too long. Technology is not
user friendly, offering little useful information and is extremely slow to obtain. The environment
on the unit is too noisy with numerous interruptions. There is a lack of education on handoff
during orientation and there is no educator to support the process. Lastly, the staff culture is
plagued with various attitudes regarding handoff and their processes are unorganized. (See
figure 1)
According to the Joint Commission Center for Transforming Healthcare, providing a
structured process such as the Hand-off Communications Project can improve the RN receiver’s
perception of satisfaction by 52.9% 19. The custom for NTICU is to use blank sheets of paper in
an unstructured manner. A baseline survey was electronically emailed to all 18 RNs to gain an
understanding of their impression and satisfaction of the current unstructured method for their
handoff process. Nine of the 18 RNs responded to the five question survey. (See figure 2) 66%
of the responses indicated that they were slightly dissatisfied with knowing the patients story
after handoff. 77% of the respondents answered slightly satisfied with having sufficient enough
information to care for their patients after handoff.
To understand the pre project handoff process the project lead observed a total of ten
different shift to shift RN handoffs, five on each shift. The current handoff process,
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 7
demonstrated by seasoned and newer critical care nurses within the department, substantiated
being a challenge with relaying information appropriately. The observations demonstrated the
various aspects of the shift to shift RN handoff in the NTICU. First, the RNs meet one on one
and provide verbal report at a crowded nurse’s station. Second, nurses utilizes a paper tool that
they are most comfortable with for the handoff process. Many of these tools were blank sheets
of paper. While others were quite detailed. Third, the electronic record is utilized very little for
shift to shift handoff. The nurses find the current software to be cumbersome as well as time
consuming. After the nurses receive the verbal handoff from the previous shift, they spend
considerable amount of time in the EMR researching the patient and what has occurred during
their critical care hospital stay. This practice is not a nurse satisfier. The nurses frequently
identified omissions from the handoff process later during their shift. In one research study,
nurses on surgical units had an increase of 33% of patient information to keep track of more than
medical units during shift to shift handoff.20 Among trauma patient populations, there are usually
lengthy informative patient story that is difficult to convey shift to shift and day to day for each
patient. This information must be accurately conveyed for a period of weeks or longer. This
demonstrates the need for a more structured handoff process.
The project team reviewed evidence based literature, tools, and anecdotal reports from
previous experience and various organizations to develop a new handoff process. Criteria was
developed by the team for the desired process. The project team designed a formalized tool for
handoff on the eight bed NTICU. This resulted in an abridged version SBAR format in paper
form. (See figure 3) By removing the Assessment sections from the piloted SBAR tool, each
individual nurse reported a head to toe assessment separately from the piloted tool. This allowed
the RN staff flexibility to customize their head to toe assessment.
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 8
After numerous formal and informal project team meetings, a card stock paper tool was
developed for the Situation and Background and Recommendation sections of the standard
SBAR report process. The RN staff determined what was to be included in the tool which was
kept in the patient’s binder for the duration of their stay. These things included: diagnosis (Pt
Story), procedures, abnormal/critical labs values on admission, and pertinent history. These
things were written in pen on admission. Also included were: family dynamics/concerns,
physician/patient & family plan, blood products, and current lines/tubes/devices which were
updated each shift in pencil. The project champions elicited feedback from the remainder of the
NTICU staff. It was determined that the proposed project will be implemented for four weeks.
The week prior to project initiation, the project lead performed several educational
sessions with NTICU RNs and secretaries to explain the project details and implementation
process. Questions were answered and the value to the nurse and patient was reinforced eliciting
buy in from team members
Do Stage (Phase)
Lewin’s change theory was utilized for this performance improvement project. This type
of theory can help to simplify an overall complicated process and has been widely utilized
throughout the years.21 The three stages of Lewin’s theory are unfreezing, moving and refreezing.
During the unfreezing stage of the project, the current process was assessed for a period
of six weeks. Moving from the old method to the new method required ways to unfreeze the
current cultural ways of performing shift to shift handoff. Educational opportunities were
utilized such as live presentations and evidence based literature review. These methods
addressed the need for a swing in culture, understanding the impact to patient safety and
improving nurse satisfaction. For the project to be successful two RNs from the team were
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 9
informal leaders and front line champions. Without frontline champions, the new handoff
process may not have been cemented into the daily practice of all of the RNs after the project’s
completion. The handoff process might revert back to the previous habits. The project
champions were selected based on past performance with quality improvement initiatives and
passion for a change in handoff procedures. These key staff RNs assisted in performing the
RCA identifying shift to shift handoff barriers.
For the moving stage, the project champions along with the project lead initiated the pilot
change process. Education on the use of the newly developed SBAR tool was provided to 80
percent of the staff RNs. Due to census and time constraints for project initiation, the tool was
not able to be piloted prior to project initiation.
During the last stage, the refreezing stage, the newly developed handoff process tool was
implemented, tweaked and cemented into practice. The process was monitored to by the project
lead to determine adherence to the new process, for feedback and for coaching the new change in
culture. RN champions served as mentors for the rest of the team. Weekly staff huddles
determined how the process worked at the front line. Concerns were addressed during
implementation, rather than at the completion of the project.
Lewin’s change theory was complimented by a combination of Relationship-Based Care
and Transformational Leadership. It is this style of leadership that develops the team to their
maximum ability while mentoring the growth and emergence of new leaders.22 As a
transformational leader it was important to demonstrate to the staff why the change is important
and involve them in the decision making process. Transformational leaders are effective when
they listen to the stakeholders, challenge the norm, influence the process and affirm the process
progress.23 In an effort to challenge the norm, resources such as EBP tools were encouraged to be
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 10
reviewed to promote consistency and structure to the handoff process. Throughout any change
development the transformational leader will allow voices to be heard.24 Staff were encouraged
to provide feedback on the SBAR tool development. Teamwork was fostered through the group
dynamics in creating the new process. A collaborative relationship developed between the
project lead and the team coming to a common agreement on the chosen methods determined
during the process.
Eighteen RNs and six secretaries participated in implementing the NTICU Shift to Shift
Handoff Performance Improvement Project along with the nurse manager and project lead. The
SBAR tool was initiated by the RN staff for all admissions to NTICU for a period of 30 days.
The SBAR tool was made available to all staff at the secretary’s work station. Secretaries
ensured that the tool was provided to the RN during the admission process. The tool was printed
on yellow cardstock paper for visibility and durability. This helped when the patients had
extensive lengths of stay.
On the day of project initiation, the project lead along with the nurse manager, met with
both shifts at 7am to announce, reinforce the kickoff and answer questions. It was decided that
the current patients within the unit would not be included. All patients admitted thereafter to the
NTICU had the tool initiated. An iridescent colored educational poster board was displayed on
the desk of the nurse’s station for all staff to refer to. It was also a good reminder for initiating
the tool. This proved helpful for educating other clinicians about the project and the benefits of
the SBAR tool. The project lead was also available for questions and reinforcement.
Study Stage (Phase)
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 11
The process improvement project concluded after four weeks of execution. Project lead
observations revealed that nurses were devoted to filling in the SBAR tool on nearly all
admissions to the NTICU unit. After careful review of all SBAR tools against the census log of
admissions for the four week period, it was noted that 155 of 161 admissions had an SBAR tool
initiated. Of these 77 % were completed in its entirety. It was difficult to discern whether nurses
kept the tool up to date shift to shift for every day of the patient’s stay. Nurses embraced the
new tool for the information that it contained, as nurses exhibited referring to it many times
throughout the shift for clarity of patient information. Conversely, during the pilot period, the
staff voiced concerns with the value of the tool for the actual handoff process. This was
demonstrated behaviorally by the nursing staff frequently needed reminding to gather the tool
before starting the handoff report. The project lead and nurse manager frequently reinforced
utilizing the SBAR tool for shift report. It was suggested by a night shift RN that the off going
shift would pull the SBAR tools in preparation to giving handoff to the oncoming shift. This was
ensured routinely by only a few staff who were engaged in the project. Throughout the
implementation, the NTICU and organizational cultural norm was identified as a barrier to the
new process. Staff were repeatedly urged to adhere to the pilot performance improvement
project and asked for suggestions for improvement. It was apparent only a minority of the staff
were engaged during observations.
After completion of the four week period, a 5 question survey was sent to the RN staff to
determined nurse satisfaction and if the SBAR tool enhanced the handoff project. (See figure 4)
It was revealed that the staff found the tool to not aide in the handoff process. 90% of the
respondents stated that they were completely dissatisfied with the lack of keeping the tool up by
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 12
each shift. 90% of the respondents also revealed that they were somewhat satisfied with
knowing the patients story, but indicated in the comment section when it was kept up to date.
Act Stage (Phase)
Future projections for the NTICU handoff project is dismal. Without executive support
for reactivating the structured handoff project it will not endure. Internal culture and external
driving forces played a key factor in the lack of success of this handoff project. Most
importantly, the executive leaders of the organization must imbed the concepts of a culture of
safety in operational strategies which ensure resources for culture of safety initiatives
encompassing all staff, including physicians. 25 All clinicians need to be fully educated on the
concepts of a culture of safety and how vital it is to restructure the handoff process. Once this
occurs, the newly developed shared governance committees should be actively involved with the
development and strategy for insisting that a formalized process be adopted at an organizational
level. The shared governance committee and executive leaders should visit Magnet Hospitals to
observe practices that are evidence based. It has been demonstrated that process improvement
projects that promote a culture of safety are more effective when administrators ascertain
processes from organizations of high reliability. 26 Organizations with high reliability for
handoff ensure that communication flows dependably. 27
Externally, there were many factors that inhibited the success of daily handoff processes.
Competing priorities and initiatives took time away from the team and the nurse manager from
focusing on ensuring the project moved forward. Additionally, this department was the only area
attempting to impact a safe patient handoff. The NTICU nursing staff felt as though it was unfair
that the rest of the organization did not have to conform to any structure. This allowed them to
not place the importance of the project as a high priority in their nursing practice. Also,
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 13
fundamental to the project’s success would be to educate all hospital employees that handoff
time periods are sacred. Patients should not be transferred during this time period, phone calls
should be minimized, procedures should not be scheduled during this timeframe, as well as
traffic and noise should be kept to a minimum. It has been revealed that interruptions and
distractions can account for an increase in errors. 28
One distinction noted is empowering nurses to speak up for safe handoff practices is a
necessity. The nursing staff are often frustrated with lack of information provided, however they
are unable to channel this energy into actionable changes. They feel inhibited to ask for more
information when handoff is inadequate. Many staff feel intimidated to speak up against the
cultural norm. The nursing staff must be empowered to say they will not accept a bad report
from another individual in the moment. Shared governance structured models often help nurses
feel empowered to enhance changes that support patient safety. 28
SBAR tool in computer could be instrumental to its success. As it would provide
populated information from the care that was performed without the nurses having to write it
down. It was apparent from observations as well as survey feedback, that the staff felt as though
it was extra work.
Conclusion
Accurate handoff is essential for safe patient care and for nurses understanding the
patient’s story prior to beginning patient care. Although there are strong recommendations to
formalize the handoff process, many organizations continue to struggle with implementing these
changes. The NTICU attempted to make such a change with a formalized SBAR tool. Despite a
well thought out project plan, including an RCA and Lewin’s theory of change the
Organizational barriers such as not having an organizational presence of a culture of safety,
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 14
proved to be the largest barrier to its success. Further work in establishing a genuine culture of
safety could prove to be instrumental as well as a Failure Mode and Effect Analysis to ensure the
attainment of a structured handoff procedure.
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 15
References
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http://www.centerfortransforminghealthcare.org/assets/4/6/CTH_Hand-
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Communication ToolsStaff Process
EnvironmentEducationTime
Constraints Technology
Inefffective RN to RN Shift Handoff
Omissions
Lack accountability
Sidebar conversations
Culture
Attitudes
Unorganized
Varies
No one to enforce
Not Evidence Based
Assignments
In a hurry to leave
Too long No Orientation
Not clearly defined
//
No educator
Poor quality Info
Slow
Not User friendly
Noisy
Interruptions
Patient Needs/Acuity
Inconsistent
Opinions
No handoff policy
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 17
Figure 1. Root Cause Analysis.
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 18
Figure 2. Baseline RN Survey
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 19
Figure 3. SBAR Handoff Tool
NTICU SBAR Patient Information for Handoff Report(To be kept in pts binder and retrieved for report)
Diagnosis (Pt story)Admission Date to NTICU:____________________Code Status________****
Procedures:
Pertinent History:Diet_________________
Activity:_____________
Abnormal/critical lab values on admission:
SCANS/Results:______________________________
Current LINES/Tubes/Devices: (Use pencil-keep up to date)Ventilator/ETT_______________________________________Central Line_____ DATE:_____ PICC ______ DATE _______Art Line____________________ DATE:_______JP____________________JP____________________Chest Tubes- R___________ L __________ (Clamps in room?)_____
Ventric- R ____________ L ___________Cooling Device________@______ Warming Device__________Foley____________ N/G-O/G_______________OTHER:___________________________________________TPA__________________
DPOA:_________________________________Phone:_________________________________Family Dynamics/Concerns:
Physician /Pt & Family Plan: Coag Products receivedPRBCs_______________________________________________ FFP___________ Cryo ________ PLTs
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 20
_____________________Vitamin K_________
Please place in the basket at the desk when patient is discharged! PT STICKERReturn form to Marie Wendt Tube 208, SICU if sent to medical records
Figure 4. Post Implementation RN Survey
ADAPTING SBAR HANDOFF TO SIMPLIFY THE PATIENT'S 21