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Journal of Caring Sciences, 2013,2(3), 177-185

http:// journals.tbzmed.ac.ir/ JCS

A Standardized Shift Handover Protocol: Improving Nurses’ Safe Practice

in Intensive Care Units

Javad Malekzadeh1, Seyed Reza Mazluom1, Toktam Etezadi1*, AlirezaTasseri2

Department of Nursing, Faculty of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran.
Department of Nursing, Javad-Al- Aemeh Hospital, Mashhad, Iran.


Article type:
Introduction: For maintaining the continuity of care and improving the quality of care,
Original Article effective inter-shift information communication is necessary. Any handover error can
endanger patient safety. Despite the importance of shift handover, there is no standard
handover protocol in our healthcare settings.
Article History: Methods: In this one-group pretest-posttest quasi-experimental study conducted in
Received: 1 Oct. 2012
Accepted: 29 Nov. 2012
spring and summer of 2011, we recruited a convenience sample of 56 ICU nurses. The
ePublished: 27 Agu. 2013 Nurses’ Safe Practice Evaluation Checklist was used for data collection. The Content
Validity Index and the inter-rater correlation coefficient of the checklist was 0.92 and
89, respectively. We employed the SPSS 11.5 software and the Mc Nemar and paired-
Keywords: samples t test for data analysis.
Shift handover
Patient safety Results: Study findings revealed that nurses’ mean score on the Safe Practice
Intensive care unit Evaluation Checklist increased significantly from 11.6 (2.7) to 17.0 (1.8) (P < 0.001).
Nursing care Conclusion: using a standard handover protocol for communicating patient’s needs
and information improves nurses’ safe practice in the area of basic nursing care.

Introduction term complications, and fourteen percent

Delivery of safe and proper health care is died. The important fact was that 69% of
extremely important to patients’ health. these errors were potentially preventable.3
Currently, a wide range of safety issues has Following this study, a report of the Institute
challenged the healthcare delivery and of Medicine in 1999 surprised healthcare
therefore, many personal and organizational providers and costumers greatly. In this
strategies have been developed for report—entitled ‘To err is human: building a
promoting patient safety.1 safer health system’—it has been estimated
Previously, people believed that hospitals are that medical errors cause 44000–98000 cases
safe places for receiving medical treatments.2 of in-hospital death in the United States each
Early in the 1990s, the results of a study year.4 These statistics changed the public’s
conducted by Harvard University in UK attitude towards the safety of medical
aroused the first concerns about patient treatments and triggered many political
safety. The results of this study showed that endeavors in the United States to find the risk
during the course of the study, 98000 patients factors for medical errors and to improve
experienced serious injuries as a result of patient safety.2
medical errors. Fifty seven percent of these The studies conducted by the Joint
patients recovered from the injuries one Commission International (the WHO
month later, seven percent experienced long- Collaborating Centre for Patient Safety

* Corresponding Author: Toktam Etezadi (MSc), E- mail:Etezadit1@mums.ac.ir

This study was extracted from the MSc thesis in Mashhad university of medical sciences, No: 89568.

Copyright © 2013 by Tabriz University of Medical Sciences

Malekzadeh et al.

Solutions) revealed that poor information second national goal of safety. This goal
communication is the main risk factor for emphasized the communication of up-to-date
65% and the contextual risk factor for 90% of and credible information that minimally
sentinel events.1 Information communication disrupts the shift handover process.6To
happens repeatedly among healthcare achieve this goal, numerous shift handover
providers. One of the instances of formats such as ‘I PASS THE BATON’
information communication in healthcare (Introduction, Patient, Assessment, Situation,
settings is during the nursing shift Safety, THE, Background, Action, Timing,
handovers. Effective handover facilitates the Ownership, Next), ‘SHARQ’ (Situation,
continuity of care and enhances patient History, Assessment, Recommendations,
safety.5 Questions), ‘5 Ps’ (Patients, Precaution, Plan,
Shift handover is a common tradition among Problems, Purpose), and ‘SBAR’ (Situation,
nurses; however, standard and effective Background, Assessment, Recommendation)
handover and information communication were developed and used worldwide.11 These
skills are not taught formally during nursing formats improved the quality of inter-shift
academic education; rather, nurses learn such information communication in different
skills during their daily practice and form hospital units worldwide.
more experienced nurses.6-7 The primary goal In our country, Iran, the shift handover
of shift handover is to communicate the reports are usually given verbally using the
patients’ clinical information and to provide a patient Kardex and not based on an
safe and high-quality care; however, poor integrated protocol. However, the contents of
information communication during Kardexes do not necessarily reflect the
nonstandard and ineffective shift handover patient’s caring priorities.11 The lack of an
may endanger patient safety.8 Evidence integrated handover protocol in our country
shows that ineffective shift handover in addition to the inappropriateness of the
increases the risk of medication error and international shift handover formats for our
sentinel events, delays the course of healthcare settings have made the
treatment, decreases patient satisfaction, and standardization of the shift handover
prolongs the length of hospital stay. The difficult. Currently, there are two types of
results of a study on pregnant women accreditation standards for hospitals
showed a significant correlation between the worldwide including the JCAHO (Joint
number of shift handovers and unplanned Commission Accreditation of Health
cesarean deliveries.7 Hansten found that a Organization) and JCI (Joint Commission
low-quality change-of-shift report can lead to International). The JACHO and JCI standards
a one- to two-hour delay in the delivery of have been developed for the accreditation of
nursing care.9 On the other hand, Reader et healthcare settings in the developed and
al. reported that ineffective intra-shift and developing countries, respectively.12 On the
inter-shift verbal and written other hand, available handover formats such
communications are responsible for respect- as SBAR have been designed based on the
tively 57% and 37% of all the healthcare specifications of the developed country and
errors.10 Consequently, effective commun- therefore are not applicable to the Iranian
ication of the patients’ clinical information is healthcare settings.
a key factor in the delivery of a safe and high- As mentioned earlier, effective information
quality care. Effective information commun- communication is very important in all
ication is so much important that in 2005 the healthcare settings; however, the importance
American Committee of Safety referred to the of effective information communication in
standardization of information commun- the intensive care units (ICUs) is twofold
ication process in health care system as the because

178 | Journal of Caring Sciences, September 2013; 2 (3), 177-185 Copyright © 2013 by Tabriz University of Medical Sciences
Standardized shift handover and nurses’ safe practice

1. In ICUs, nurses are the chief healthcare were developed by the study researchers. The
providers and hence spend a great deal of demographic questionnaire consisted of eight
time and energy on the collection, questions regarding participants’ age,
integration, and utilization of patients’ data gender, overall work experience in nursing,
for caring purposes.13 work experience in ICUs, main working shift
2. ICU patients usually are not able to and working unit, academic degree, and
participate in their self-care activities and satisfaction in monthly working shift pattern
therefore are very vulnerable to the medical measured on a dichotomous Yes/No scale.
errors.14 The SHEC was designed based on the JCI
To prevent the occurrence of preventable standards and physical examination of all the
errors and improve patient safety through body systems. The handover skills of each
effective handover information communi- individual nurse were observed for three
cation, we designed a comprehensive and times in different day or evening working
practical handover protocol based on the JCI shifts. Accordingly, 168 episodes of shift
standards. The aim of this study was to handover were observed.
investigate the effects of this protocol on the For designing the NSPEC, we needed to use
nurses’ safe practice in intensive care units. caring standards and protocols to determine
nursing interventions that their omission
Materials and methods resulted in adverse consequences.
This was a one-group pretest-posttest quasi- Accordingly, we collected all the routine
experimental study conducted in spring and nursing standards and protocols affiliated to
summer of 2011. The study population our study setting. Thereafter, we defined the
consisted of all the ICU nurses affiliated to a probable deviations from these standards and
large-scale teaching hospital located in protocols. Finally, we selected all the
Mashad, Iran. Including criteria were having deviations harmful to the patients.
a Master or Baccalaureate degree in nursing, Consequently, the 20-item NSPEC was
having at least a six-month work experience developed. NSPEC was consisted of 20
in ICUs, and participating in at least 90% of nursing interventions that, as mentioned
theoretical education classes and all the previously, their omission resulted in adverse
practical education classes held by the consequences. The possible responses to each
researchers to educate the participants the item of NSPEC were ‘Performed’, ‘Not
designed handover protocol. performed’, and ‘Not indicated. Items were
We recruited a convenience sample of 56 scored on a dichotomous scale in which score
nurses for the study. For calculating the 1 stood for ‘Performed’ and score 0 stood for
study sample size, we conducted a pilot ‘Not performed’ responses. ‘Not indicated’
study with participating ten eligible nurses items were deleted and their scores were
and used the findings in the following added to other items. Consequently, the
sample size calculation formula: possible range of the total score of NSPEC
N=((Z1– α /2 + Z1– β) 2×(S12+S22))/(Mean1–Mean2) was 0–20.
Finally, with a confidence level of 95% and a To determine the validity of SHEC and
power of 80%, the sample size was NSPEC, we calculated the Content Validity
determined to be 55. Index (CVI) of each checklist. The CVI of
For data collection, we used a demographic SHEC and NSPEC was 0.94 and 0.92,
questionnaire, the Shift Handover Evaluation respectively. The reliability of these two
Checklist (hereinafter briefly referred to as checklists was assessed using the inter-rater
SHEC), and the Nurses’ Safe Practice reliability method. One of the researchers and
Evaluation Checklist (hereinafter briefly a researcher assistant concurrently observed
referred to as NSPEC). All the instruments and documented the shift handover skills

Copyright © 2013 by Tabriz University of Medical Sciences Journal of Caring Sciences, September 2013; 2(3), 177-185|179
Malekzadeh et al.

and safe practice of 12 nurses. Accordingly, nurses’ practice regarding patient safety, we
we calculated the correlation between the observed their caring behavior for a whole
two series of scores for each checklist. The working shift. On the other hand, other
inter-rater correlation coefficient for SHEC nurses whose SHEC scores were below 80%
and NSPEC was 0.95 and 0.89, respectively. were subjected to additional three half-an-
The main purpose of the study intervention hour practical education sessions.
was to change the nurses’ shift handover 3. Refreezing: in this stage the change agent
behavior; therefore, we used the Kurt Lewin’s attempts to fix the after-the-change state of
Change Theory.15 Lewin believed that a equilibrium. Accordingly, he encourages the
successful change project consists of three group members to follow the learned
stages: behaviors and prevents them from the re-
1. Unfreezing: Lewin believed that some adopting the old ones. In this study to attain
disequilibrium in the status qua is the pre- the goal of refreezing, we strictly supervised
requisite for behavior change. In this stage, the nurses’ adherence to the protocol, asked
factors and forces that maintain the status qua the head-nurses to encourage and support
should be unfrozen and removed. In the the nurses in the implementation of the
current study we established face-to-face protocol, and asked the nurse-managers to
contacts with the ICU head-nurses, issued reward those nurses who were in compliance
formal announcements, and employed with it.15
hospital trustworthy workers and authorities
Data analysis
to attain the goal of unfreezing. These
We employed the version 11.5 of the
activities initiated informal discussions
Statistical Package for Social Sciences, SPSS
between nurses and generated some degree
11.5, for data management and analysis.
of uncertainty among them. Accordingly, the
Initially, we checked the normality of the
nurses started to seek new information
study variables using the Kolmogrov-
regarding shift handover. They also started to
Smirnov and Shapiro-Wilk tests. The results
think and discuss about the new handover
of these tests showed that all the study
protocol and its advantages and
variables, except for the total score of NSPEC,
disadvantages as well as probable restraining
had a non-normal distribution. Subsequently,
forces of change. Consequently, they reached
to facilitate the data analysis process, we
a state of disequilibrium and their resistance
transformed the non-normally distributed
to change was broken down.
variables using the square root
2. Change: in this stage, the change agent
transformation. Accordingly, we described
develops and implements the most effective
the data using descriptive measures such as
change strategies. In this study, we
frequency, percentage, mean, and standard
theoretically educated nurses the developed
deviation. On the other hand, for comparing
handover protocol in two 90-minute sessions
the nurses’ before- and after-the-intervention
held in two successive days. Accordingly, we
NSPEC scores, we employed the McNemar
practically educated each individual nurse
and paired-samples t tests.
the handover protocol in three half-hour
sessions held in three successive days. The Results
practical education sessions held at the time
of inter-shift handover. One week after these Most of the study participants (68%) were
educations, we observed and evaluated the female nurses. The mean and standard
nurses’ shift handover skills using the SHEC. deviation of nurses’ age and work experience
Nurses who obtained at least 80% of the total in ICUs were 31.0 (4.7) and 3.1 (2.9) years,
SHEC score were subjected to safe practice respectively. Most of our participants (98.2%)
evaluation using the NSPEC. To evaluate held baccalaureate degree in nursing and

180 | Journal of Caring Sciences, September 2013; 2 (3), 177-185 Copyright © 2013 by Tabriz University of Medical Sciences
Standardized shift handover and nurses’ safe practice

51.8% of them worked in rotational working intervention mean score had increased by
shifts. Moreover, 59% of nurses were satisfied 46.5%.
with their monthly working shift pattern. Moreover, the results of the McNemar test
The results of the paired-samples t test revealed that except for the item 6
revealed that secondary to the study (Documentation Intake/Output in each
intervention, nurses’ mean score on the working shift) and 16 (Documenting the date
NSPEC increased significantly from 11.6 (2.7) of naso-gastric tube insertion), the number of
to 17.0 (1.8) (P < 0.001). In other words, nurses who performed the remaining 18
compared to the before-the-intervention caring items of NSPEC increased significantly
mean NSPEC score, the nurses’ after-the- after the intervention. (P< 0.05); (Table 1).

Table 1. Nurses’ safe practice before and after the study intervention
Before the intervention After the intervention
Caring items Performed Not Performed Not P
Performed Performed
N (%) N (%) N (%) N (%)
Assessment of the level of consciousness using
45(80.7) 11(19.3) 53(96.3) 3(3.7) 0.000
the Glasgow Coma Score
Assessment of the patient’s need for physical
29(51.3) 27(48.7) 47(84.6) 8(15.4) 0.007
Verification of the patient’s identity (writing
the patient’s name at the beginning of the 24(42.5) 32(57.7) 35(62.9) 21(37.1) 0.000
nursing report)
Routine eye care once a shift 12(21.1) 44(78.9) 55(98.2) 1(1.8) 0.000
Routine mouth wash once a shift 46(81.4) 10(18.6) 55(97.6) 1(2.4) 0.000
Documentation of patient’s intake and output
55(98.2) 1(1.8) 55(99.4) 1(0.6) 0.625
once a shift
Assessment of fluid balance in the last six
14(24.6) 42(75.4) 40(72.1) 16(26.9) 0.000
Inspection of the potential pressure ulcer
25(43.8) 31(56.2) 51(90.6) 5(9.4) 0.000
Routine position change 17(31) 39(69) 51(91) 5(9) 0.000
Intervention for promoting defecation during
3(4.5) 53(95.5) 34(60.9) 22(39.1) 0.000
the first three days after the patient complaint
Routine wound care 27(48.6) 28(51.4) 54(95.7) 2(4.3) 0.000
Care for areas under pressure 23(40.2) 33(59.8) 48(86.3) 8(13.6) 0.000
Routine hand wash before each procedure 27(49.1) 28(50.9) 48(85.3) 8(14.7) 0.000
Documentation of abnormal laboratory tests 33(58.2) 23(41.8) 51(90.2) 5(9.8) 0.038
Establishing communication even with
29(51.3) 27(48.7) 43(77.2) 13(22.8) 0.000
unconscious patients
Documentation of the NG tube insertion date 56(100) 0(0) 56(100) 0(0) 0.985
Verification of the placement of NG tube
10(18.7) 46(81.3) 39(69.2) 17(30.8) 0.000
before each enteral feeding
Routine change of NG tube 33(58.9) 23(58.9) 41(73.3) 15(26.7) 0.000
Measurement and documentation of residual
12(20.6) 44(79.4) 42(74.5) 14(25.5) 0.000
gastric contents before each feeding
Irrigating the NG tube after each feeding 51(91.2) 5(8.8) 55(99) 1(1) 0.008
Total NSPEC score* 11.6(2.7) 17(1.8)
The results of paired-samples t test t =12 df=55 P=0.000
Values are expressed as mean (SD).

Copyright © 2013 by Tabriz University of Medical Sciences Journal of Caring Sciences, September 2013; 2(3), 177-185|181
Malekzadehet al.

Discussion intervention, this value increased to 73.1%.

The results of this study showed that nurses’ This increase highlights the important role of
NSPEC scores increased significantly after effective information communication skills in
the study intervention. In other words, the increasing patient safety during nursing
implementation of the designed shift interventions.
handover protocol improved the nurses’ On the other hand, we found that only 11.5%
performance in terms of patient safety of nurses measured and documented the
through updating their caring program, residual gastric contents before each feeding.
maintaining the continuity of care, and After the study intervention, this value also
improving the quality of inter-shift increased to 95.4%. Studies showed that
information communication. enteral feeding is the most common route of
Because of the strong emphasis of the nutritional support in hospitalized patients.
designed protocol on the inter-shift On the other hand, aspiration is the most
communication of information regarding the common and most serious complication of
skin, urinary and gastrointestinal systems enteral feeding.19 Careful assessment and use
health, the improvement in nurses’ skin, of preventive measures such as verifying the
urinary, and gastrointestinal care (items placement of naso-gastric tube (hereinafter
number 2, 4, 6, 7, 8, 9, 11, 12, 14, 17, and 19) briefly referred to as NG tube) and
was remarkable. Intake and output measuring the residual gastric contents
monitoring for preventing fluid loss or before each enteral feeding as well as keeping
overload is a rather simple nursing task in the head of bed elevated 30–45 degrees
ICUs; however, error of omission and nurses’ during enteral feeding decrease the risk of
malpractice in this area have been cited in aspiration.20 Before the study intervention,
many studies.16 According to the Nursing our nurses either did not measure the
and Midwifery Association in 2007, intake residual gastric contents or did not know
and output record is a key component of how to manage it. The most common caring
routine nursing care and therefore, it should strategy pursued by our participants to
not be omitted because of insufficiencies such manage high residual gastric contents was to
as staff shortage or nurses’ time limit. This discontinue enteral feeding for one to two
Association proposed that nurses have to rounds. They adopted this strategy without
control the patients’ intake and output measuring and documenting the amount of
strictly and document and report any intake residual gastric contents. The findings of
and output imbalances.17 On the other hand, previous studies showed that enteral feeding
Perren questioned the accuracy of fluid should be discontinued only when the
balance charts used in many ICUs. He residual gastric content is more than 150–200
reported that fluid imbalance is more milliliters.19,21 High residual gastric content is
prevalent in unconscious patients and a warning sign; however, it is not a good
patients unable to communicate verbally.18In rationale for discontinuing enteral feeding.
the current study, careful system-by-system Rather, enteral feeding should be continued
physical examination of patients helped under careful supervision. Otherwise,
nurses recognize fluid imbalance signs and repeated discontinuation of enteral feeding
symptoms. Moreover, the implemented may result in negative calorie balance 22. A
protocol increased their ability to very important point in measuring the
communicate these signs and symptoms residual gastric contents is that besides
correctly during change-of-shift reports. We residual food stuffs, it consists of salivary and
found that only 24.6% of nurses documented gastric enzymes; therefore, when aspirated
the intake and output of fluids. After the for measuring the residual gastric contents, it
should be returned to the stomach again.
182 | Journal of Caring Sciences, September 2013; 2 (3), 177-185 Copyright © 2013 by Tabriz University of Medical Sciences
Standardized shift handover and nurses’ safe practice

Otherwise, the patient may experience fluid should be checked at least once a
and electrolyte imbalance. We found that shift.21Although the routine auscultation
before the study intervention, most of our method is not a reliable method for verifying
nurses missed this point. On the other hand, the placement of NG tube, our nurses did not
prokinetic agents like Metoclopramide and use even this simple method before the
Erythromycin increase the rate of gastric study. However, after the study, inter-shift
emptying and improve enteral feeding information communication regarding the
tolerance while digestive disorders like patient’s normal peristalsis, persuaded the
constipation may result in enteral feeding incoming nurses to think about the
intolerance 20. We included all these displacement of the tube and to verify its
considerations in our handover protocol. The proper placement. The results of the study
study findings revealed that nurses’ per- revealed that the after-the-study number of
formance in areas such as residual gastric nurses who checked the placement of NG
content measurement, abdominal auscul- tube before feeding increased significantly by
tation, and assessment of abdominal 50.5%.
distension and bowel evacuation increased Inappropriate use of physical restraints may
significantly (from 11.5% to 94.5%) after the result in many complications including new
intervention pressure ulcers, nosocomical infections, fall
The effects of errors of commission (such as and injury, joint contracture, orthostatic
rapid administration of intravenous hypotension, death wish, urinary
potassium chloride) are like the effects of incontinence, and increased mortality rate.
errors of omission (such as taking no action The physical restraining of intubated or
for hypokalemia).23Errors of commissions are severely ill patients may result in the
more prevalent in healthcare settings; omission of pain assessment. ICU patients
however, errors of omission in ICUs are usually suffer from different levels of pain
potentially more detrimental.24 In ICUs, and restlessness secondary to factors such as
many decisions are momentous and if not disease complications, invasive interventions
made timely, may result in serious injuries. (such as suctioning), therapeutic and
Kumar et al. found that during the first six monitoring devices (such as catheters, drains
hours of septic shock-induced hypotension, and intra-tracheal tubes), and dressing
every one hour delay in the initiation of change. Improper pain assessment and
antimicrobial therapy decreases the survival management may compel nurses to restrain
rate by 7.6%.25 the patient physically. Continuation of pain
As, in ICUs, nurses bear most of the and restraining, in turn, result in sleep
responsibilities for patient care, they are the deprivation, disorientation, and stress
chief agents for both initiating and detecting response activation. Activation of stress
life-threatening events. Accordingly, response in an acutely ill patient may finally
documentation and early report of abnormal result in delirium. Delirium, in turn, increases
laboratory findings is an effective strategy for the length of hospital stay, healthcare costs,
the prevention of healthcare errors and and mortality rate. Such painful experiences
promotion of patient safety. are precursor of posttraumatic stress disorder
Verifying the proper placement of NG tube in and long-term cognitive disabilities.26This
stomach before each entreat feeding is an cascade of complications highlights the
important aspiration prevention strategy. In importance of appropriate use of physical
patients having normal peristalsis, the tip of restrains particularly in ICUs, wherein
the feeding tube may displace or dislodge patients are not able to communicate
easily and enter the esophagus. The tube verbally. The results of the current study
length and proper placement of the tube revealed that inter-shift communication of

Copyright © 2013 by Tabriz University of Medical Sciences Journal of Caring Sciences, September 2013; 2(3), 177-185|183
Malekzadeh et al.

information regarding physical restraints and Conflict of interest

its rationales improves the nurses’
The authors declare no conflict of interest in
performance in terms of safe physical
this study.
Kalisch found that in ICUs a large number of
caring measures are missed. He reported that
basic nursing interventions (such as position We would like to gratefully thank the
change, mouth wash, feeding patients with managers and lecturers of Mashhad Faculty
warm food, skin care, bath, etc.) are missed of Nursing and Midwifery as well as head-
by 73% of ICU nurse.27 We also found that nurses and staff nurses who helped us
eye care and position change were missed by conducting this study. We also appreciate the
78.9% and 60% of nurses, respectively. In our Research Administration of Mashhad
study, implementing the shift handover University of Medical Sciences which
protocol and increasing nurses’ knowledge supported this study.
about patients’ needs improved the quality of
nursing care; however, more studies are References
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