Are Patients and Family Members an Essential Aspect of Bedside Handoff?

Similar to many important initiatives in health care, we have been talking about bedside handoff report for several years. Handoff became a Joint Commission National Patient Safety Goal in 2006; the goal was to provide more structure to the reporting process to address errors caused by miscommunication.¹ Handoff is defined as real-time effective communication to transfer specific information, knowledge, and patient responsibility from one member of the health care team to another for provision of continued safe patient care.¹ 

Key attributes associated with effective hand-off include a standardized approach allowing opportunity for both parties (giver and receiver) to participate in face-to-face communication (when possible) with few interruptions; asking questions; exchanging accurate patient information concerning care, treatment, condition, and changes (real or anticipated); and providing an opportunity for the receiver to review historical patient data.¹  Most health care disciplines are involved in some type of handoff communication. Handoff occurs in several situations including shift report, temporary or on-call coverage, transfer of patients between units or facilities, and communication of critical laboratory or radiology reports.¹  This editorial will focus on handoff as it applies to the nursing shift report.

Handoff was considered a standard of practice by 2010, and was replaced on The Joint Commission National Patient Safety Goal list in 2012 by other priority safety initiatives.²  In 2017, The Joint Commission published a Sentinel Alert Event titled “Inadequate Hand-off Communication,” which stressed the importance of standardized communication to achieve the goal of patient safety. This Sentinel Alert reiterated many of the previously published expectations, with the addition to engage patients and family members during care transitions when possible.³ 

Standardized handoffs often include the use of a structured tool or checklist to guide the hand-off process.⁴  Although research is ongoing to find the best handoff process to promote patient safety, we are encouraged to provide handoff at the bedside where the patient can be visualized and the patient and family member can participate. One intensive care unit incorporated patient and family questions into the end of the structured bedside handoff to address any patient preferences and concerns.⁵  Many of you may have successfully implemented bedside handoff report involving patients and family members, but others have not.

Patients should be able to define their family to include anyone of importance to them and determine how their family will participate in care and decision-making.⁶  Patient- and family-centered care is defined as “an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care professionals, patients, and families.”⁶  Information sharing, participation, and collaboration with patients and families are core concepts. As described, patient- and family-centered care is much more than just a way of sharing information from the nurse to the patient and family.

In AACN Scope and Standards for Critical Care Nursing Practice,⁷  standards promote and expect the incorporation of patients and families into our practice. These standards state that patient and family values and preferences should drive our care decisions. A core value of the American Association of Critical-Care Nurses is to ensure that our practice is patient and family focused.⁷  Nurses frequently engage with patients and families, but do we treat them as health care partners? As nurses, we are strong advocates for our patients and families. Why do we not advocate more loudly for their participation in handoff?

No one disputes the active role that acute and critical care nurses have in patient care and safety, but who knows the patient better than the family? Nurses frequently work with nonverbal patients in acute and critical care settings. Without the family’s involvement, would the nurse know which side the patient prefers to lie on when falling asleep? Does the nurse know which toy is the favorite of the 2-year-old toddler in their care? Would the nurse recognize that an agitated patient has always had a strong aversion to having other people touch his hair?

Is it possible that we have different standards of care for involvement of patients and families when it comes to care across the lifespan? Do we embrace family participation differently when the patient is a neonate, a child, an adult, or an elderly patient? Do we center handoff more around the needs of the health care professionals than the patient? The thought of involving patients and family members in handoff may be intimidating. What if they do not understand or misunderstand what we are discussing?

Nurses talk about implementing beside handoff but have had difficulty sustaining the practice change over time. A systematic review revealed that barriers to bedside handoff included concerns about the amount of time needed for patient- and family-centered handoff, lack of support by peers, and potential breaches in patient confidentiality.⁸  Staff at one pediatric intensive care unit with a successful bedside handoff program worked around some of these concerns by discussing any sensitive issues outside of the patient’s room at the end of each handoff.⁵ 

Many benefits have been associated with bedside hand-off involving patients and family, including increased patient and family satisfaction, perception of better care, and an improved understanding of the patient’s condition.^5,8  Researchers found an increase in trust and knowledge by the patients and family and a perception that staff respected their needs.⁸  In a few studies, investigators found an association between bedside handoff and improved patient outcomes, such as a decrease in patient fall events and medication errors, attributed to improved communication after implementation of bedside handoff.^5,8 

Investigators have reported a decrease in the time taken to complete handoff when it is performed at the bedside,⁸  possibly related to staying on task and having fewer interruptions when joined by patients and family members. Nurses reported an increase in their own satisfaction following the implementation of bedside hand-off, citing improved teamwork and work environment, and improved communication with colleagues and patients.^5,8  Staff in one unit found that sustainability of bedside rounding is an ongoing challenge, despite favorable outcomes for patients, families, and nurses.⁵ 

Bedside report is about more than who knows the patient best, it is about sharing information and learning to trust and respect each other. It is about working collectively toward a common goal to provide the best and safest care possible for our patients. Without patient and family involvement in handoff, we may be making a lot of assumptions about what is best for our patients’ most personal needs.

The concerns expressed about the provision of bedside handoff involving patients and families remind me of the resistance experienced in the past regarding the transition to open visitation policies. Many barriers and fear of the unknown initially held us back from embracing open visitation, and yet now it has become a standard of care in most units. Like many things that we do, movement toward performing handoff in the patient’s room and engagement of patients and families require a blend of persistence and patience. It may take several tries before we get it right and before we feel comfortable with the new normal. Many variables affect our daily practices, and this practice is no different. In the end, it feels like the right thing to do. CCN