Research Article

Journal of Patient Experience

1-6
Impact of Structured Clinical Handover ª The Author(s) 2021
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Protocol on Communication and Patient DOI: 10.1177/2374373521997733
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Satisfaction

Sayani Ghosh, MSc1, Lakshmi Ramamoorthy, MSc, PhD2 ,

and Biju pottakat, MS, MCh3

Abstract
The Handover process is an essential aspect of patient care in daily clinical practice to ensure continuity of patient care.
Standardization of clinical handover may reduce sentinel events due to inaccurate and ineffective communication. Single arm
experimental trial was conducted to assess the effect of standard Situation, Background, Assessment, Recommendation
(SBAR) protocol implementation in overall bedside nursing handover process, patient satisfaction, and nurses’ acceptance. As
a sample, all nursing staff of specified unit, all handover process performed by them, and patients admitted during study the
period were included. Initially, the prevailing handover process and patient satisfaction regarding nursing handover was
assessed using a structured observation checklist. During the implementation phase, nurses were trained on an SBAR
handover protocol. After implementation, nursing handovers were again assessed and data regarding patient satisfaction and
nurses’ acceptance were collected. There was a statistically significant difference (P < .05) in median scores between the pre
and post-intervention group on overall nursing handover and patient satisfaction regarding nursing handover. Standardization
of patient’s handover process is effective in terms of improving nursing handover process, patient satisfaction, and health
professionals’ acceptance.

Keywords
patient satisfaction, clinical hand over, quality care, nursing care, handover protocol

Introduction responsibility and accountability for the care of a patient are

transferred from one nurse to another. Numerous patient-
Hospitals are the place where various methods of communi-
specific information is transferred during this time. Transfer
cation take place. Multiple numbers of healthcare profession-
and acceptance of responsibility for patient care are attained
als take care of the patients during any patient’s treatment
through successful communication (3).
period in health care settings. Each caregiver working with
This is also the high time where communication may be
a patient must provide accurate and updated information to
inaccurate and the handover process may become ineffec-
other caregivers (1). Clinical handover is an important com-
tive. The Joint Commission identified communication fail-
ponent to maintain continuity of patient care further patient
ure as the major cause of patient suffering (4). To organize
engagement and communication at transitions of care improve
information in clear and concise format which will help in
patient care outcomes, prevent adverse events during care,
facilitating effective communication among health care
and reduce readmissions to hospital after discharge. To ensure
patient safety after handing over, right information should be
transferred and accepted by the right people at the right time. 1
College of Nursing, JIPMER, Puducherry, India
Nursing handovers take place thrice or more times in a day 2
College of Nursing, JIPMER, Puducherry, India
3
according to the shift timings and as necessary. Nurses are Department Surgical Gastro Enterology, JIPMER, Puducherry, India
legally responsible and accountable for transferring important
Corresponding Author:
patient-specific information during handovers (2,3). Lakshmi Ramamoorthy, College of Nursing, JIPMER, Gorimedu,
The handover process plays an important role in nurses’ Puducherry.
day-to-day clinical practice. During nursing handovers, Email: [email protected]

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2 Journal of Patient Experience

providers; the Situation, Background, Assessment, Recom- study was obtained from the Institute ethical committee,
mendation (SBAR) model was developed. A systematic Human studies, Reg. No: JIP/IEC/2018/018. Trial registration
review of nursing handover has reported SBAR as the most was done under the Clinical Trials Registry—India (ICMR-
frequently used handoff tool (5,6). Situation, Background, NIMS), Reg. No: CTRI/2018/09/015835.
Assessment, Recommendation refers to a patient handover
system in which Situation refers to patient’s name, age, sex,
bed number, and chief complaint for admission. Background
Sample Size and Selection Criteria
refers to the patient’s admitting diagnosis and number of Complete enumeration was used for participation in the study.
hospital stays since admission and past history. Assessment All staff nurses working in the surgical gastroenterology ward
refers to patient’s recent vital signs and other diagnostic and patients admitted in the same ward during the study
reports and present clinical condition. Recommendation period (5 months) were included in the study. A total of
refers to patient’s management of the condition (7). 2696 nursing handover processes, 52 patients, and 10 nurses
Structured clinical handover has been shown to reduce were enrolled in the study using an observation checklist and a
communication errors within and between health service structured questionnaire. Among the total 2696 observed nur-
organizations and to improve patient safety and care because sing handover processes, 1226 were observed during the pre-
critical information is more likely to be accurately trans- intervention period, 1226 were observed during the
ferred and acted on (1,2). This is especially important at postintervention period, 122 were observed during the second
transitions of care, when communication errors are more month audit, and 122 were observed during the third month
likely and there is an increased risk of information being audit. Among 52 patients, 26 patients were included during
miscommunicated or lost. Ineffective communication at the preintervention period and 26 were included during the
clinical handover is also associated with clinicians spending postintervention period.
extensive time attempting to retrieve relevant and correct
information (3). This can result in inappropriate care and the
possibility of misuse or poor use of resources.
Procedure
It can be hazardous to both patients and staff if the hand- As represented in Figure 1, during the preimplementation
over is ineffective, such as incomplete information or wrong phase, handing over strategy was assessed with the help of
information provided (6–8). Different hospitals, units, and a structured observation checklist, and data regarding patient
nurses follow different methods of delivering shift reports. satisfaction regarding their involvement in the plan of care
Irrelevant, narrative, and repetitive information often hampers with the nursing handover process was assessed by the inves-
the communication process. Moreover, nursing handoffs take tigators which included 2 members team. This checklist
place at busy times of the day with multiple distractions and included 4 items on Communication of plan of care to
time constraints which makes shift reports more likely to have patients, patients satisfaction on information provided about
errors (9,10). Therefore, communication methods should be a plan of care, whether the outgoing nurse introduced the
standardized by incorporating the SBAR framework in it. This oncoming nurse during the change of shift to the patients,
standardization can help in sequencing information exchanges Presence of open communication between health care pro-
and promoting patient safety during handover. viders regarding patient’s plan of care.
Involving the patient in the nursing handover process by Then the nurses were trained on SBAR handover protocol
allowing them to ask their queries and provide information (which includes situation, background, assessment, and rec-
regarding plan of care can improve patient satisfaction. ommendation) with the help of lecture cum discussion and
Involving patients in nursing handover also makes them Self-instructional module followed by demonstration on
aware of their respective nurses in each shift which helps handover using SBAR protocol by the investigators. After
in building good nurse–patient relationship (8,10). Chances implementation of standardized nursing handover protocol,
of fragmentation of patient care and miscommunication again handover practice and patient satisfaction regarding
related to adverse incidents are reduced when patients are the information provided to them during handover time and
involved in handovers and leads to greater continuity of care. their participation in plan of care were assessed. Nurses’
acceptance toward the implemented protocol was assessed
during postintervention period. Compliance to the imple-
Method mented standardized protocol was checked at 2-month and
3-month interval. The major part of data was collected by
Study Design participant observation method, as investigator was posted in
A single-arm experimental trial was done to assess the effect that specific area for clinical experience.
of standardized nursing handover protocol implementation on
overall bedside nursing handover, patient satisfaction, and
nurses’ acceptance. The secondary outcome was to assess the
Data Collection Instruments and Scoring
compliance of the nurses toward the implemented protocol at The data of demographic profile and handover timing con-
the end of the second and third months. Permission for the sisted of 4 variables namely shift time, days, educational
Ghosh et al 3

113%

87.52% 86.13% 88.58% 88.25%

90%

68%
54.64%
45.06%
45% 39.21%
32.52%

23%

0%
Situation Background Assessment Recommendation

Pre-intervention group Post-intervention group

Figure 1. Comparison of SBAR components compliance after implementation of Standardized handover protocol. SBAR indicates Situ-
ation, Background, Assessment, Recommendation.

qualification, and experience in years. Based on educational the handover was given by the graduate nurses (72.49% and
qualification, the study participants were categorized as BSc 74.71%). According to years of experience, the groups were
Nursing, MSc nursing, and GNM. Experiences were categor- almost equally divided into 2 categories that is, 0 to 5 years
ized as from 0 to5 years’ experience, 5 to 10 years’ experi- and 6 to 12 years. Physical presence that is, face-to-face
ence, and more than 10 years’ experience. Components of a handover was present always (100%) in both the pre- and
standardized nursing handover protocol section include the 5 postintervention group. Compliance of SBAR and all other
categories (time, place, process, interaction, and patient components of the standard nursing handover process were
communication) against which the nursing handover prac- more appreciated in the postintervention group as repre-
tice was assessed. A single part questionnaire was developed sented in Figures 1 and 2. There was a significant difference
to collect data regarding patient satisfaction on nursing hand- (P < .05) in the median scores between the preintervention
over and to collect data regarding nurses’ acceptance of the and postintervention on overall nursing handover. Hence, the
introduction of standardized nursing handover protocol nursing handover was significantly improved after the
which consisted of 7 questions. implementation of a standardized protocol. Also, there was
Two marks were given for the presence of SBAR com- a significant difference (P < .05) in the median scores
ponents and 0 marks for absence. For other components, 1 between the preintervention and postintervention on patient
mark was given for the presence of action and 0 for absence. satisfaction regarding nursing handover. Hence, patient
Thus, total marks were 14 for the overall nursing handover satisfaction regarding nursing handover significantly
score. To interpret, the score was distributed as >11 (>80%) improved after the implementation of a standardized proto-
as satisfactory and <11 (<80%) as unsatisfactory. Regarding col (Table 1).
patient satisfaction, the answer related to high satisfaction is The secondary outcome was to assess the compliance of
given a score of 3 and the least satisfaction gets a score of 1. the nurses toward the implemented protocol at the end of the
Thus, a total of 12 marks were allotted under patient satis- second month and third months. The result reveals that there
faction. Content validity index (0.74) was established to was no significant difference (P > .05) in the median scores
check the relevance of the items in the tool. The reliability among immediate postintervention and during second audit
of the tool established by the test retest method was found to (at the end of second month) and third audit (at the end of
be 0.8. third month) on overall nursing handover, which indicates
there was good compliance to the implemented standardized
protocol at immediate postintervention period and at 2
Results months and 3 months intervals also.
Regarding duty shift timing, there was an almost equal per- The correlation between the SBAR score and the overall
centage of observation in each shift in both pre- and post- handover score in the pre- and postintervention period and
intervention groups were observed. Regarding the day of audit points was done. At each point, the result indicates a
observation, a maximum number of observations are done good positive correlation between the SBAR score and the
on the weekdays (64.21% and 69.33%) in both pre- and overall nursing handover score which indicates the improve-
postinterventional groups. In both groups, the majority of ment of the overall handover score was due to better
4 Journal of Patient Experience

125%

100%100%
100% 93.80%
89.97%
85.32% 86.02% 84.01% 84.99%
79.86%
75%

50% 45.29%

21.96% 20.36%
25%

0%
Specific Duration Physical Bedside Information Read back
time presence to patient
Pre-intervention group Post-intervention group

Figure 2. Comparison of other components standard nursing handover compliance among pre- and postintervention group.

Table 1. Comparison of Nursing Handover and Patient Satisfaction Score in the Pre- and Postinterventional Group.a

Preintervention (n ¼ 1226) Postintervention (n ¼ 1226)

Area of assessment Median Interquartile range Median Interquartile range P value

Overall clinical handover score 7 (5–9) 13 (11–14) .000#

Patient satisfaction score 11 (10–12) 12 (11–12) .024*
a
N ¼ 2452
b
Wilcoxon signed-rank test.
c
Mann-Whitney U test; P < .05.

Table 2. Association Between Overall Clinical Handover Score With Nurse’s Demographic Variables and Handover Timing.a

Total handover score

Parameters Satisfactory handover score Unsatisfactory handover score P valueb

Educational qualification of nurses BSc Nursing 687 75% 229 25% .001c
Msc Nursing 135 81.82% 30 18.18%
General Nursing Midwifery 91 62.76% 54 37.24%
Shift time Morning 341 83.78% 66 16.22% .000c
Evening 299 73.46% 108 26.54%
Night 273 66.26% 139 33.74%
Days Weekday 649 76.35% 201 23.65% .009c
Weekend 213 68.05% 100 31.95%
Holiday 51 80.95% 12 19.05%
Experience 0-5 years 467 74.72% 158 25.28% 0.445
6-12 years 446 74.21% 155 25.79%
a
N ¼ 1226.
b
Fisher exact test; P < .05.
c
P < 0.001.

utilization of SBAR protocol. The results are statistically (0.000), and days (0.009) are associated with the total hand-
significant (P < .05). Table 2 shows the association between over score. The experience of the nurses is not associated
overall nursing handover score with nurse’s demographic with the total handover score. The handover score was satis-
variables and handover timing. The findings show that the factory among the MSc nurses, morning shift and during
educational qualification of nurses (0.001), shift time holidays, which was significant at P < .05.
Ghosh et al 5

Discussion compliance to the implemented standard nursing handover

protocol at 2- and 3-month intervals also. In a study conducted
In the present study, standardized SBAR nursing handover
by Achrekar et al, compliance to SBAR documentation was
protocol implementation had a positive effect on bedside
done by auditing retrospectively at first week and 16th week,
nursing handover. The overall nursing handover score after
after the introduction of the self-instructional module. There
implementation of SBAR protocol was higher in the post-
was a statistically significant difference invalid percent score
intervention group compared to the preintervention group.
of 4% between the 2 audit points. A significant improvement
The overall nursing handover score included 5 categories
(P ¼ .043) in overall scores between audit points was seen.
(time, place, process, interaction, and patient communica- This difference was thought to be due to the regular practice
tion) against which the nursing handover practice was of the implemented form (20).
assessed. In all 5 categories, there was an improvement in There are some limitations to this study. Since the study
the postintervention group. Similar findings were reported in was conducted only in one ward, the findings may not be
a study conducted by Crompton et al, the result of the study generalizable. Though the participant observation method
demonstrates improvement in hospital communication using was followed, there is the possibility of the Hawthorne effect
SBAR format (11-12). A systemic review conducted by which can affect the study result.
Muller et al shows average evidence for improvement of
patient safety through SBAR communication protocol,
mainly when used in telephonic conversation (13). Conclusion
In the present study, patient satisfaction was assessed The current study supports the need for standardization of
during the pre- and postintervention period using a struc- the nursing handover process by incorporating SBAR proto-
tured questionnaire containing 4 questions. The patient satis- col in it. The standardization was effective in improving the
faction score regarding nurses’ handover process nursing handover practice. So, it is concluded that the imple-
significantly increased in the postintervention group com- mentation of a standardized nursing handover process is
pared to the preintervention group. Whereas, the results of effective in terms of patient satisfaction and nurses’ accep-
other studies indicate positive but not significant difference tance. This study can be used as a future reference since it
after implementing standardized SBAR protocol in nursing emphasizes quality improvement of the handover process by
handover. The findings of the study conducted by Townsend standardizing it.
et al conclude as patient satisfaction was trended toward a
positive result, but was not significant (14). Acknowledgment
The SBAR has an encouraging impact on improving com- The authors acknowledge Dr Tanveer Rehman, Department of Pre-
munication between nurses and increasing their job satisfac- ventive and Social Medicine, JIPMER, for statistical analysis and
tion. Thus, the application of such a standardized instrument presentation of data of the study.
retains and reassures good communication relationships
(15–17). In this study, nurses’ acceptance was analyzed dur- Authors’ Note
ing the postintervention period using a structured question- The study was approved by Institute ethics committee. Informed
naire that contains 7 questions related to acceptance. The consent was obtained from every participant and nurses after a brief
items included in all 7 questions, nurses gave positive explanation regarding the study by the investigator.
responses to the implemented standardized nursing handover
process. The result of the study conducted by Abela et al Declaration of Conflicting Interests
showed that the structure of handover procedures and the use The author(s) declared no potential conflicts of interest with respect
of the SBAR tool can improve the impact of handover and to the research, authorship, and/or publication of this article.
staff satisfaction. Satisfaction regarding the information
received during handover increased from 34% to 41% Funding
(19). In the result of the study conducted by Fabila et al, The author(s) received no financial support for the research, author-
recipients’ perception about the new handover protocol indi- ship, and/or publication of this article.
cated improvement in information adequacy and clearness,
decrease errors, and lesser inconsistencies in the patient ORCID iD
described in the new procedure (18,19). Lakshmi Ramamoorthy, MSc, PhD https://orcid.org/0000-0003-
In the present study, compliance to the implemented nur- 4248-1407
sing handover protocol was assessed by conducting auditing
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