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Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 12-20

Handoff communication: Hallmark of nurses

Junior Lecturer, College of Nursing, CMC, Vellore, India

Date of Web Publication11-Jun-2020

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Communication is a vital element in the health care setup. National Patient Safety Goals 2018 proposed by The Joint Commission highlights the importance of communication among the caregivers. Breakdown in communication was the leading cause of sentinel events reported to the Joint Commission in the United States of America between 1995 and 2006. Majority of the errors can be prevented if the ‘Handoff or ‘handing over’ communication is up to the standard. A handoff is a transfer and acceptance of patient care responsibility achieved through effective communication. It is a realtime process of passing patient specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care. Handoff process includes exchanging of information, transferring the responsibility of care and preparing the team to take over, and ensuring the continuity of care. Handoff need not be only during the change of shift, it can be even during stepping down or stepping up of a patient, transferring for any procedures, transferring between units, or facilities and discharge. The potential barriers in implementing the effective handoff communication includes resistance of caregivers to change, time constraints, cost constraints, low health literacy, poor staffing, cultural and language differences, failed leadership, and lack of information technology infrastructure. Nursing handoff can be enhanced by incorporating technology.

Keywords: Communication, handoff, ISBAR, I PASS, SIGNOUT, PACE, SHARQ, SHARED

How to cite this article:
Suganandam DK. Handoff communication: Hallmark of nurses. Indian J Cont Nsg Edn 2018;19:12-20

How to cite this URL:
Suganandam DK. Handoff communication: Hallmark of nurses. Indian J Cont Nsg Edn [serial online] 2018 [cited 2022 May 28];19:12-20. Available from: https://www.ijcne.org/text.asp?2018/19/1/12/286083

  Introduction Top

Communication in healthcare setting is a vital link in delivering comprehensive patient care. As immediate and vital caregivers, nurses need to be proficient in communication skills and be able to effectively communicate with patients and other health team members. Communication can positively impact the perception and experiences of patients and members of the health care team. Communication among the team members foster better coordination, promote excellence, diminish medical errors and improve long term outcomes for patients and the organization. National Patient Safety Goals (2018) proposed by The Joint Commission (2014) highlights the importance of communication among the caregivers. Breakdown in communication was the root cause of sentinel events reported to the Joint Commission in the United States of America between 1995 and 2006 (World Health Organisation [WHO], 2007). Majority of the errors can be prevented if the ‘Handoff or ‘handing over’ communication is appropriate and meets the standards. In a study by Starmer et al. (2014) effective handoff program had significantly reduced the medical errors and preventable adverse events and improved the quality of written and oral handoff without a negative effect on workload.

  Handoff Top

A handoff is a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real time process of passing patient specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care (The Joint Commission, 2014). Handoff is a complex process which is passing on the authority, responsibility, and accountability in order to ensure the continuity of care and not just merely passing on specific information. The effectiveness of handoff invariably depends on the communication between the sender and receiver. In a complex health care setup, handoff occurs numerous times. The frequency of these handoffs increases the chance of losing a critical piece of information during the transition. In fact, poor quality and incomplete handoffs play a role in 80% ofpreventable adverse events (O’Reilly, 2010).

Handoff process typically involves three phases (Patton, 2007).

  • exchanging information
  • transferring responsibility of care
  • providing continuity of care by preparing the team that is taking over so they are able to anticipate and make timely decisions

Patients’ and Nurses’ Satisfaction related to Handoff

Handoff can influence the patient satisfaction to a great extent. When a patient is being shifted from one level of care to another, it is not only the health care team members who provide and receive information but also the patient who will receive relevant communication. Traditionally nursing handoff occurs in nurses station or conference room which is away from the patient bed side. The current trend and expectation is that the handoff should occur at the patient bedside. From the nurses’ perspective, it aids in getting a better picture of the patient with room for clarifications and promotes opportunity for general assessment. Whereas from patients’ point of view, it enables them to participate in the care and identify the care provider for the shift. Further, it promotes better understanding of the existing condition, enhances patient safety and ameliorates patient satisfaction. Ford, Heyman, and Chapman (2014) studied patients’ perception on bedside handoff and it revealed that there was a significant relationship between bedside handoff and patient satisfaction, understanding of their care, feeling of safety, and participation in the care. Many other studies support the above findings (Jeffs et al., 2014; Radtke, 2013).

Effective handoff not only improves patient satisfaction and safety but also ensures the nurses’ satisfaction. Thomas and Donohue-Porter (2012) reported that the nurses’ satisfaction improved significantly following the implementation of an organized handoff process. Nurses felt that they gained good knowledge about the patients and their condition and also there was a chance to question and clarify the doubts. It also paved an opportunity for teaching at the point of care and partnered assessment. Although there was a reluctance in the initial period of implementation of organized bed side handoff, later with the leadership support and regular training nurses were found to be highly satisfied with the bed side handoff process. It empowered nurses and ascertained their accountability in patient care and safety.

  Types of Handoff Top

Handoff can occur in any setting of the health care organization. It can be at change of shifts, or between different services or to a different discipline. According to Friesen, White, and Byers (2008), the types of handoff can be

  • shift to shift
  • nursing unit to nursing unit
  • nursing unit to diagnostic area
  • nursing unit to special areas
  • discharge and inter-facility transfer

Handoffs can also occur when a staff needs to leave the unit for a short time (e.g., meal breaks or meetings), change of assignments, when patient acuity changes or when other team members leave units (Patton, 2007).

  Tools Used in Handoff Top

Handoff can be tailormade according to the institution policy, feasibility, user feedback, available resources, etc. Most of the frames explained may not be feasible in every setting. But it is essential to have a set framework for the effective handoff process. Handoff tool can vary based on the area i.e., acuity and availability of staff members, and resources. Technological explosion led to the usage of Computer On Wheels (COWs) during the handoff. There are commercially available softwares such as Hands on Automated Nursing Data System (HANDS), Safer Sign Out, Smart Sign Out, Sign Out, etc., which enables the handoff process to be easier. In few areas, traditional method of handwritten book is still in practice. Irrespective of the tool used for handoff, the ultimate goal is to ensure the continuity of care and safety of the patient. There are few cited mnemonics which can be used in any health care setup during handoff.


Brownstein and Schleyer (2007) with an attempt to reduce the medical errors, near-misses and also to improve the high quality care, came up with a mneomonic ‘HANDOFFS’. It helps to establish a standardized datasheet which provides all critical information about the patient and also aids in teaching the skill. The description is given in [Table 1].
Table 1: HANDOFFS tool

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ISBAR (Introduction, Situation, Background, Assessment, and Recommendation) or SBAR (Situation, Background, Assessment, and Recommendation) is widely used in health care settings recently. This system of communication originated in the US Navy for use in nuclear submarines and also in airline industry thereafter. It was initially used as SBAR and later ISBAR was introduced in health care setup by prefixing ‘Introduction’ (Aldrich, Duggan, Lane, Nair, & Hill, 2009). The application of ISBAR communication in health care setup is illustrated in [Figure 1].
Figure 1: ISBAR Handoff Tool

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It organizes a conversation in to essential elements in the transfer of information. It enables the nurses to report concise, pertinent, and complete verbal information and minimizes the risk of communication error. ISBAR organises a conversation into the essential elements in the transfer of information from one source to another. Its effectiveness has been demonstrated in both clinical and non clinical situations of communication transfer.

The ISBAR approach is

  • simple and quick to use
  • memorable
  • portable
  • logically structured

ISBAR creates a shared mental model for the transfer of relevant, factual, concise information between clinicians. It flattens the hierarchy and so eliminates the power differences that may inhibit information flow.


A multicentric study conducted in US and Canada proposed the usage of I PASS to promote patient safety (Starmer et al., 2014). Ineffective handoff can lead to fatal error and sentinel events. Inorder to curb the preventable adverse events, I PASS was initiated. It is an evidence based standardized approach to teach, evaluate, and improve the handoff. The key elements of I PASS bundle is mentioned in [Table 2].
Table 2: I PASS Handoff Tool

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I PASS the BATON is modified form of I PASS. It has incorporated few aspects from ISBAR and I PASS. Agency for Health care Research and Quality (AHRQ) in its Team Strategies & Tools to Enhance Performance and Patient Safety (STEPPS) incorporated I PASS the BATON in the Communication domain (AHRQ, 2013). Wheeler (2014) suggested the use of this handoff tool which concealed the gaps in communication and prevented misinterpretation. It also paved the way to ask questions and clarify doubts immediately. The elements are depicted in [Table 3].[Table 5]
Table 3: I PASS the BATON Handoff Tool

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Table 4: SIGNOUT Handoff Tool

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Horwitz, Moin, and Green (2007) developed an acronym ‘SIGNOUT’ based on SBAR in order to develop a standardized curriculum for a safer handoff. Though SBAR is a valid tool in communication, it was not followed because of its complexity. This SIGNOUT simplifies the aspects and is appreciated by the health care team members for its practicality.


Schroeder (2006) designed an original template based on the pneumonic PACE. It improves the patient safety and ensures continuity of patient care in these four categories. Usage of PACE is depicted in [Figure 2].
Figure 2: PACE Handoff Tool

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Situation, History, Assessment, Recommendations/ Results and Questions (SHARQ) was a validated handoff tool used by Sandlin (2007) among Perioperative nurses. Significant errors reduced following the implementation of SHARQ handoff tool. The components of SHARQ is explained in [Table 5].
Table 5: SHARQ Handoff Tool

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Mathias (2006) reported the usage of SHARED handoff tool in improving communication while caring for a surgical patient. It helped to share a unified report in a comprehensive concise manner without missing any information about the patient. The usage of SHARED tool is described in [Table 6].
Table 6: SHARED Handoff Tool

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  Guidelines for Implementing Effective Handoff Top

Prerequisites for Hand-off

Although many tools are available, certain prerequisites are needed to make the tool and the overall handoff communication to be effective (Patton, 2007). Firstly, there should be consistency in using the handoff tool every time the handoff occurs. Variations in the type and tools between team members or between units can lead to confusion and missing out of vital information. Secondly, verbal face to face handoff is the best mode to minimise errors in information. Although recorded and virtual handoffs are suggested, face to face handoff provides the best opportunities for two way communication and clarifications. Thirdly, the exchange of information must be a two way process. Both the reporter and the receiver should be able to ask, clarify and confirm information related to the patient. Finally, the environment should be conducive for the best hand-off. Distractions and interruptions should be limited for all who are involved in hand-off to prevent missing out or forgetting information.

The Joint Commission’s guidelines elaborates on the prerequisites for implementing an effective handoff (The Joint Commission, 2017).

  • Effective and Interactive Communication

    Communication should foster an opportunity for questioning between the sender and receiver of the patient care information.

  • Up-to- date information on patient

    Details about patient condition, care planned, implemented, treatment advises, services provided and any untoward or anticipated changes, recent scenario should be updated.

  • Established process of verifying the information

    System should be in such a way that it will seek clarity through read-back or repeat-back process. There should be a provision to check and verify whether the information received is right or not.

  • Opportunity to review

    The receiver should have an opportunity to review the relevant patient data received from the sender. It can be data pertaining to history, presenting symptoms, care provided, treatment, and services.

  Barriers to Effective Handoff Top

Health care setting will have its own hurdles in implementing the effective handoff system. Barriers to handoff include internal factors, external factors, or any special situations. According to Welsh, Flanagan, and Ebright (2010), the barriers identified during handoff process are

  • minimal information shared during report
  • too much of information shared during report
  • inconsistency in the quality of information
  • restricted opportunity to clarify and ask question
  • malfunction of equipment that may be used during handoff (e.g. ,Telephone)
  • numerous interruptions

Runy (2012) as cited in Vanderberg (2013) identified ten barriers to effective handoffs as

  • Inadequate training on handoff procedure
  • Importance of of individual autonomy
  • Patients and family members not engaged in the process of care
  • Staff members resistance to change
  • Time constraints
  • Physical settings issue such as light, noise, interruptions
  • Language barriers
  • Unclear mode of communication
  • Failure to identify and adapt best practices for handoffs
  • Lack of financial resources and institutional support to implement policies and protocols

The barriers can also be broadly grouped under the following five factors (Aguda, 2017) (see [Figure 3])
Figure 3: Barriers to Effective Handoff

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  Solutions to Improve Handoff Top

The Joint Commission put forth certain solutions to improve the Hand off communication in the health care organization (The Joint Commission, 2017).

  • Administration and leadership commitment to safety through implementing handoff communication protocols
  • Standardizing hand off procedure and process (the content, tools and methods for handoff should be tested and validated)
  • Involving multidisciplinary team, making every one in the health care team responsible in handing off
  • Commitment to training all levels of team members in handoff procedure and process
  • Monitoring effectiveness by audits and feedbacks on process implemented and continuous improvement
  • Making effective handoff communication process an organizational culture

  Conclusion Top

Improving handoff in health care institutions can bring about phenomenal change in the patient outcomes. It is clearly evident that it not only improves the patient satisfaction but also of the team members. Improvising and adapting new handoff technique which is feasible for an institution is a mandate as it ensures continuous quality improvement. Nurse leaders should involve in policy making, provide adequate resources, plan rigorous training, and offer constant support to enable the implementation of effective handoff process. Effective handoff is a hallmark of Nursing Care. Handoff communication augments the patient safety initiatives implemented in any health care organisation.[22]

Conflicts of Interest: The author has declared no conflicts of interest.

  References Top

Aguda, E. (2017). Handoff communication: A survey study of what anesthesia providers need to know. (Unpublished doctoral thesis). University of Michigan, Michigan.  Back to cited text no. 1
AHRQ. (2013). Pocket guide on team strategies & tools to enhance performance and patient safety. Retrieved from https: //www. ahrq. Gov /sites/ default/ files/wysiwyg/ professionals /education/ curriculum- tools /teamstepps /instructor /essentials/ pocketguide. pdf  Back to cited text no. 2
Aldrich, R., Duggan, A., Lane, K., Nair, K., & Hill, K. (2009). ISBAR revisited: Identifying and solving barriers to effective clinical handover in inter-hospital transferpublic report on pilot study. Newcastle: Hunter New England Health.  Back to cited text no. 3
Brownstein, A., & Schleyer, A. (2007). The art of HANDOFFS: A mnemonic for teaching the safe transfer of critical patient information. Resident and Staff Physician, 53(6), 15.  Back to cited text no. 4
Ford, Y., Heyman, A., & Chapman, Y. L. (2014). Patients’ perceptions of bedside handoff: The need for a culture of always. Journal of Nursing Care Quality, 29(4), 371-378.  Back to cited text no. 5
Friesen, M. A., White, S. V., & Byers, J. F. (2008). Handoffs: Implications for nurses. In Hughes, R. G. , Creating a Safe and High-Quality Health Care Environment-Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Retrieved from https ://www.ncbi.nlm.nih.gov/books/NBK2651/?ter m=patient%2 0 s afety%2 0 and%2 0quality ?  Back to cited text no. 6
Horwitz, L. I., Moin, T., & Green, M. L. (2007).Development and implementation of an oral sign-out skills curriculum. Journal of General Internal Medicine, 22(10), 1470-1474.  Back to cited text no. 7
Jeffs, L., Beswick, S., Acott, A., Simpson, E., Cardoso, R., Campbell, H., & Irwin, T. (2014). Patients’ views on bedside nursing handover: Creating a space to connect. Journal of Nursing Care Quality, 29(2), 149154.  Back to cited text no. 8
Mathias, J. M. (2006). A SHARED tool strengthens handoffs. OR Manager, 22(4), 15.  Back to cited text no. 9
O’Reilly, K. B. (2010). Joint Commission quality initiative reduces poor patient handoffs. American Medical News. Retrieved from http://www. pwrnewmedia.com /2010/jc01130bignews/download_cth/CTH_America n_Medical_News_handoffs.pdf  Back to cited text no. 10
Patton, K. A. (2007). Handoff communication: Safe transitions in patient care. Retrieved from http://www.usahealthsystem.com/workfiles/com_doc s/gme/2011 %2 0Workfiles/Handoff%2 0 Communication Safe%20Transitions%20in% 20Patient%20Care.pdf  Back to cited text no. 11
Radtke, K. (2013). Improving patient satisfaction with nursing communication using bedside shift report. Clinical Nurse Specialist, 27(1), 19-25.  Back to cited text no. 12
Sandlin, D. (2007). Improving patient safety by implementing a standardized and consistent approach to hand-off communication. Journal of Perianesthesia Nursing, 22(4), 289-292.  Back to cited text no. 13
Schroeder, S. J. (2006). Picking up the PACE: A new template for shift report. Nursing 2006, 36 (10), 22-23.  Back to cited text no. 14
Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., … & Lipsitz, S. R. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371(19), 1803-1812.  Back to cited text no. 15
The Joint Commission. (2014). Improving transitions of care: Hand-off communications. Oakbrook Terrace: Illinois.  Back to cited text no. 16
The Joint Commission. (2017). Inadequate handoff communication. Sentinel Event Alert, 58, 3-7.  Back to cited text no. 17
Thomas, L., & Donohue-Porter, P. (2012). Blending evidence and innovation: Improving intershift handoffs in a multihospital setting. Journal of Nursing Care Quality, 27(2), 116-124.  Back to cited text no. 18
VandenBerg, A. K. (2013). Patient Handoffs: Facilitating Safe and Effective Transitions of Care. (Unpublished master’s thesis). Kirkhof College of Nursing, Michigan.  Back to cited text no. 19
Welsh, C., Flanagan, M., & Ebright, P. (2010). Barriers and facilitators to nursing handoffs: Recommendations for redesign. Nursing Outlook, 58(3), 148-154. doi: 10.1016/j.outlook.2009.10.005  Back to cited text no. 20
Wheeler, K. K. (2014). Effective handoff communication. OR Nurse, 8(1), 22-26.  Back to cited text no. 21
World Health Organization. (2007). Patient Safety Communications. Communication during patient hand-overs. Patient Safety Solutions, 1(3), 1-4.  Back to cited text no. 22


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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