UCSF

Effective handoff communication is critical in promoting patient safety. At change of shift, nurses exchange patient information, but little is known about nursing handoff practices and patient safety.

The purpose of this research was to examine nurses' perspectives on handoff practices that promote patient safety and to identify conditions and processes that pose risks for patient care.

This grounded theory study was conducted in two medical-surgical units in an urban academic institution with a purposive sample of 21 nurses using semistructured interviews and 87 ethnographic observations. Data were collected and analyzed simultaneously using constant comparison and positional mapping.

Nurses maintained patient safety during handoffs by painting a full picture of patients so that oncoming nurses were well-prepared with information to prioritize assessments and detect changes in a patient's condition. Processes that promoted painting a full picture were organizing information, asking and answering questions skillfully, and engaging in respectful dialogue. Conditions that facilitated painting a full picture were respect, trust, time, private space, and face-to-face oral communication. Interpersonal tensions, lack of time, interruptions, and noise often hindered nurses' practices and jeopardized patient safety. Nurses' perceptions of the effectiveness of handoffs often depended on the position of the nurse in the handoff as either the oncoming or offgoing nurse.

Quality handoff information depended on an offgoing nurse arriving at handoff with a grasp of their patients. To acquire a grasp, nurses gathered and synthesized information throughout their shift. As nurses did so, they were actively constructing the story of the patient. Processes that facilitated constructing the story were receiving good handoff reports, assessing the patient, cueing in, and writing it down. While constructing the story, nurses were prioritizing assessments and detecting patient changes. Poor handoff reports, staffing constraints, and unpredictable patient flow challenged nurses in constructing the story. Nurses may arrive at the handoff with a poor grasp posing risks for patients.

Future research interventions need to consider the position of the nurse in the handoff. Research comparing handoff practices in units with good and poor clinical environments is needed.