Review of the literature
Order Description
Write a paper (1200 words) in which you analyze and appraise each of the (15) articles identified in Topic 1. Pay particular attention to evidence that supports the problem, issue, or deficit, and your proposed solution.
Hint: The Topic 2 readings provide appraisal questions that will assist you to efficiently and effectively analyze each article.
1.Why was the study done? Was there a clear explanation of the purpose of the study and, if so, what was it?
2.What is the sample size? Were there enough people in the study to establish that the findings did not occur by chance?
3. Are the instruments of the major variables valid and reliable? How were variables defined? Were the instruments designed to measure a concept valid (did they measure what the researchers said they measured)? Were they reliable (did they measure a concept the same way every time they were used)?
4.How were the data analyzed? What statistics were used to determine if the purpose of the study was achieved?
5.Were there any untoward events during the study? Did people leave the study and, if so, was there something special about them?
6.How do the results fit with previous research in the area? Did the researchers base their work on a thorough literature review?
7.What does this research mean for clinical practice? Is the study purpose an important clinical issue?
Refer to “Sample Format for Review of Literature,” “RefWorks,” and “Topic 2: Checklist.”
Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
Topic 2: Checklist
Review of Literature and Incorporating Theory
Instructions:
This checklist is designed to help students organize the weekly exercises/assignments to be completed as preparation for the final capstone project proposal. This checklist will also serve as a communication tool between students and faculty. Comments, feedback, and grading for modules 1-4 will be documented using this checklist.
Topic Task Completed Comments / Feedback Points
Review of Literature
• Analyze and appraise each of the 15 articles identified in module 1. (15 articles). _____ / 90
• Analysis organized using the sample provided in “Sample Format for Review of Literature.”
_____ / 10
Total _____/100
Incorporating Theory • Identified a theory that can be used to support proposed solution. _____ / 10
• Main components of theory described. _____ / 10
• Rationale for selecting theory provided. _____ / 10
• Discussed how theory works to support proposed solution.
_____ / 5
• Explained how theory will be incorporated into project. _____ / 5
Total _____/40
Original Article
Translating an Evidence-Based Protocol
for Nurse-to-Nurse Shift Handoffs
Marlene Dufault, RN, PhD, Cathy E. Duquette, RN, PhD, CPHQ, NEA-BC, Jeanne Ehmann, RN, MS, CPHQ,
Rose Hehl, RN, BS, Mary Lavin, RNP, MS, Valerie Martin, RN, MS, NE-BC, CHE, Mary Ann Moore, RN, BS,
Shirley Sargent, RN, MS, Patricia Stout, RNP, MS, Cynthia Willey, PhD
ABSTRACT
Purpose: Ineffective communication is the most frequently reported cause of sentinel events in U.S.
hospitals. Examining hospital processes and systems of communication, and standardizing communication
practices can reduce the risks to patients in the acute care environment. The purpose of this paper
is to describe the use of an innovative, translating-research-into-practice model to generate and test a
cost-effective, easy to use, best-practice protocol for nurse-to-nurse shift handoffs in a medium-sized
magnet-designated community hospital in the United States.
Theoretical Framework: Roger’s Diffusion of Innovations Theory was used as the overall framework
for the translational model with Orlando’s theory providing theoretical evidence for the best practice
protocol.
Approach: Using the first three steps of the model, methods included: (1) identifying clinical problems
related to shift handoffs; (2) appraising and systematically evaluating the strength of theoretical, empirical,
and clinical evidence; and (3) translating this evidence into a best-practice patient-centered, standardized
protocol for nurse-to-nurse shift handoffs.
Conclusions/Implications: Meaningful clinician participation in the development of a standardized,
evidence-based, patient-centered approach to nurses’ change-of-shift handoffs was achieved. Using the
Collaborative Research Utilization Model can facilitate the integration of new knowledge both in the
clinical and academic community.
KEYWORDS translational research, evidence-based clinical policy, collaborative research utilization model,
nurse-to-nurse shift handoffs, shift report, handoffs, end-of-shift report, nurse-to-nurse report, bedside
shift report, computerized report
Worldviews on Evidence-Based Nursing 2010; 7(2):59–75. Copyright ©2010 Sigma Theta Tau International
Marlene Dufault, Professor, College of Nursing, University of Rhode Island, and Research Consultant, Newport Hospital, Kingston, RI; Cathy E. Duquette, Vice President,
Nursing and Patient Care Services Newport Hospital, Newport, RI; Jeanne Ehmann, Director, Performance Improvement & Evaluation, Newport Hospital, Newport, RI; Rose
Hehl, Staff Nurse, Newport Hospital, Newport, RI; Mary Lavin, Associate Clinical Professor, College of Nursing, University of Rhode Island, Kingston, RI; Valerie Martin,
Director of Surgical Services, Newport Hospital, Newport, RI; Mary Ann Moore, Staff Nurse, Newport Hospital, Newport, RI; Shirley Sargent, Doctoral Student & Research
Assistant, College of Nursing, University of Rhode Island, Kingston, RI; Patricia Stout, Associate Clinical Professor, College of Nursing, University of Rhode Island, Kingston,
RI; Cynthia Willey, Professor, College of Pharmacy, University of Rhode Island, Kingston, RI.
This project was funded by the Delta Upsilon Chapter-at-Large, Sigma Theta Tau International, and by The Nursing Foundation of Rhode Island. We wish to acknowledge the
contributions of the University of Rhode Island College of Nursing Class of 2008; Barbara Davis, Newport Hospital librarian; Jean Taft, RN, and the Newport Hospital nursing
staff who opened their practice to the eyes of research.
Address correspondence to Marlene Dufault, PhD, RN, College of Nursing, White Hall, University of Rhode Island, Kingston, RI 02881; mdufault@mail.uri.edu
Accepted 23 January 2010
Copyright©2010 Sigma Theta Tau International
1545-102X1/10
Worldviews on Evidence-Based Nursing Second Quarter 2010 59
Protocol for Nurse-to-Nurse Handoffs
BACKGROUND AND SIGNIFICANCE
Adverse events resulting from faulty communications
are a leading cause of death and injury in hospitals
in the United States, even though there is empirical evidence
to support interventions aimed at preventing their
occurrence. In recent years, experts in health care communications
research have speculated that many omissions
of relevant patient care and missing or incorrect communication
of patient information problems are related to a
lack of research-based standards in administrative protocols
and policies (National Quality Forum [NQF] 2005).
The NQF report recommends a standardized approach to
handoff communications as 1 of 30 high-priority practices
that have strong evidence base, can be generalized,
and are likely to benefit patient safety if implemented.
Such practices were derived from the Agency for Healthcare
Research and Quality’s (AHRQ), University of California
San Francisco-Stanford University Evidence-Based
Practice Center (AHRQ 2001), and the NQF project Steering
Committee. “The transmission of care information in a
timely and clearly understandable form to patient’s current
healthcare providers who need that information to provide
care” ranks in the top-10 of this NQF-endorsed set of safe
practices (NQF, p. vii).
As accreditation and regulatory groups began targeting
communication as a quality-of-care indicator, inadequate
information transfer has expanded from an individual
administrative problem to a public health policy issue
(Joint Commission 2005). The Joint Commission has published
guidelines that specifically address recommendations
for nursing shift handoffs (Joint Commission 2005).
In its 2006 National Patient Safety Goals, the commission
requires hospitals in the U.S. to “Implement a standardized
approach to hand-off communications, including
an opportunity to ask and respond to questions.” (Joint
Commission 2005). However, integrating these guidelines
along with the findings of empirical, theoretical, and clinical
evidence into standards of care, and then translating
these into the day-to-day caregiving activities of frontline
clinicians has posed a significant challenge.
For nursing, patient safety and quality is directly
linked to correct and complete information received at
the change-of-shift interchange. Nurses’ use shift report
information in assessing patient needs, planning patient
care, establishing goals, and prioritizing and managing
their care. Hospitals in the U.S. recognize and benchmark,
(through participation in performance improvement
surveys provided by such organizations as Press-Ganey)
the toll of missing or incorrect communication of patient
information resulting in omission of patient care
and dissatisfaction from patients, families, and clinicians
(Press-Ganey 2002). For example, Press-Ganey Survey
data revealed an opportunity for improvement in scores on
variables related to patient confidence in care, their feeling
safe and secure, being kept informed, being included in
the decision-making process of patient goals, and perceiving
how well the staff work together to care for them. In
addition, nurse satisfaction related to nurse-to-nurse interaction,
teamwork among nurses, and having adequate time
for patient care was also benchmarked against the National
Database of Nursing Quality Indicators (2006).
The literature suggesting that clinicians do not apply
what is known about best handoff practices is copious
(Lamond 2000; Payne et al. 2000; Sexton et al. 2004). A
major barrier to using the evidence of current research
for attaining best handoff practice is clinician and patient
attitudes and lack of knowledge (Manias & Street 2000;
Sexton et al. 2004). Numerous studies indicate that handoffs
are often lacking in depth (Lamond 2000; Sexton et al.
2004). Nursing school curricula on handoffs is only fairly
adequate, and varies widely based on current practices in
clinical agencies in which students receive their clinical experience.
Other barriers include system problems (Hardy
et al. 2000), and lack of standards, policies, and protocols
that integrate research innovations into practice (Sherlock
1995; Joint Commission 2005).
Although significant advances in information technology
and millions of research dollars have given nurses
the tools to obtain significant data at the start of their
shift to be able to prioritize patient care and manage
their patient load effectively, the transfer of information
in a clear, timely manner that puts the patient central to
all information surrounding caregiving activities remains
inadequate. Traditional methods of shift report such as
verbal, taped, and “silent report” tend to be long, inconsistent,
and are fraught with missing or incorrect patient
information (Manias & Street 2000; Anderson &
Mangino 2006). Frequently the content reverts to irrelevant
statements or judgmental comments, leading to negative
attitudes by the oncoming nurse (Elm 2004). Poor
communication between clinicians may prolong recovery,
impede rehabilitation, or precipitate complications
especially dangerous to vulnerable hospitalized patients
who have predisposing comorbidities. Missing or incorrect
communication of patient information can result in
omissions of relevant patient care, and dissatisfaction from
patients, families, and nursing colleagues (Manias&Street
2000).
PURPOSE
The gap between what we know (research) and what we
do (practice) is at the heart of the research translation
60 Second Quarter 2010 Worldviews on Evidence-Based Nursing
Protocol for Nurse-to-Nurse Handoffs
problem in implementing a standardized approach to
handoff communications. Unfortunately, it can take 10
years for research-based approaches to become integrated
into standards for care (Coyle & Sokop 1990; Barta 1996;
Estabrook et al. 2003; French 2005). This requires an
innovative method to remove the barriers to effectively
translating these discoveries in a cost-effective manner in
order to change clinician practice in an entire organization,
improve patient outcomes, and integrate these innovations
into the education of future (student) clinicians.
Studies in research utilization and translation suggest that
organizations in which nurses practice and students learn
can either foster or inhibit the application and translation
of new knowledge into practice (Horsley et al. 1983; Titler
et al. 1994; Dufault et al. 1995; Rogers 1995; Stetler
et al. 1998a; Dufault 2001). It was believed that student
involvement in the project would facilitate future incorporation
of best practices on nurse-to-nurse handoffs into
patient care and provides students, as well as clinicians,
with an experiential opportunity to learn the process of
translating research findings to solve day-to-day clinical
problems.
The goal of this project was to use a six-step translatingresearch-
into-practice approach, the Collaborative Research
Utilization (CRU) model, to develop and test an
evidence-based, patient-centered, best practice protocol
for nurse-to-nurse shift handoffs in a 129-bed, magnetdesignated
urban community hospital. The hospital serves
a high population of tourists, the military and older adults
from the surrounding community that is similar in the
percent minorities, gender, and socioeconomic status to
other community hospitals in the state. With its full range
of services, including inpatient and ambulatory surgery,
acute inpatient care, emergency services, obstetrical, pediatric,
inpatient behavioral health services, intensive care,
inpatient and outpatient rehabilitation services, it also has
a wide range of community health education and prevention
programs. The hospital has had a highly integrated
computerized patient information and nursing documentation
system for several years. Patient acuity is typical for
a community hospital with nursing care hours per patient
day on the medical-surgical units that compares favorably
with that of other similar size and type hospitals, at 7.4
hours per patient day. In 2004, the hospital was awarded
magnet designation by the American Nurses Credentialing
Center. Contractual agreements with the state university’s
College of Nursing as a clinical site for graduate and undergraduate
students are in place.
In the first three steps of implementing this model, a
team of nurses and undergraduate and graduate nursing
students generated the evidence-based, patient-centered,
“best practice” protocol.
THEORETICAL FRAMEWORK
The overall project’s framework comes from theory in research
utilization as well as Roger’s “adoption of innovations”
theory. In addition, Orlando’s (1990) middle-range
theory provided the theoretical evidence for the specific
patient-centered, best practice protocol, and is discussed
further under Step 2 of the approach.
Adoption of Innovations Theory
The adoption of innovations theory focuses on understanding
how behavioral change is brought about in an
organizational system. According to the theory, three factors
improve research translation into practice: the availability
of a body of validated, predictable knowledge, a
cadre of clinicians competent in translating and using this
knowledge with favorable attitudes toward research, and
a supportive policy-generating structure that promotes innovation
(Titler et al. 1994; Dufault et al. 1995; Rogers
1995; Janken & Dufault 2002). Use of the CRU model,
based on Roger’s theory, addresses each of these factors.
First, the model provides for resources to review the body
of validated literature on nursing shift handoffs. Second,
faculty-led, experiential, problem-focused learning exercises
called research roundtables guide clinicians and students
to evaluate and translate this empirical knowledge.
Third, themodel provides for the organizational structures
within the hospital to create, test, and sustain the evidencebased
policies, standards, and processes needed to cue
clinician action. In the CRU model, a six-step approach
is used as adapted from the Conduct and Utilization of Research
in Nursing Project (Horsley et al. 1978). The steps
also correspond to Roger’s five-stage process of agenda
setting, matching, redefining/restructuring, clarifying, and
routinizing in the process of describing the adoption of new
practices within organizations. The sequentially designed
activities progress from step 1 to step 6 and are described
in detail in the context of Roger’s theory in Janken and
Dufault (2002).
In the model, nurse researchers are paired in teams
with clinicians, clinical specialists, and undergraduate and
graduate nursing students to address the specific clinical
issue, in this case, the development of a patient-centered,
best practice protocol for nurses’ shift handoffs based on
empirical, theoretical, and contextual evidence to support
its use.
APPROACH
Over 20 years of experience with using the CRU model
has provided insight into this strategy that helps translate
successful research-based interventions into clinician
Worldviews on Evidence-Based Nursing Second Quarter 2010 61
Protocol for Nurse-to-Nurse Handoffs
practice. Using this model to change clinician practice and
sustain organizational change had previously been applied
to other clinical problems and empirically tested in seven
other studies in which the evidence-base is strong, but underused
in practice (Tracy et al. 1995; Dufault & Lessne-
Willey 1999; Dufault & Sullivan 1999; Dufault 2004; Dufault
et al. 2006). Between 1985 and 2005, as the first step
in themodel, over 70 research roundtableswere conducted
to change nursing practice in 26 target clinical content areas
where practice lagged behind a large body of empirical
knowledge (Tracy et al. 2006). Since 2005, an additional
25 roundtables have been conducted in areas related to systems,
processes, and the environment of care. It had never
been used to design and test a standardized, evidencebased,
patient-centered approach to handoff communications
for present and future clinicians. An advantage of
using the CRU model to formulate best practice standards,
policies, and protocols is that it may improve the clinical
environment by translating research-driven change in
practice, as well as to develop present and future clinicians
who are competent in these skills.
The six steps of the approach are:
1. Identification of the clinical problem and assessment
of the empirical, clinical, and theoretical evidence for
potential translation.
2. Evaluation of the relevance of the empirical evidence
as it relates to the selected problem, agency values,
standards and policies, and potential cost and benefits.
3. Designing a policy, standard of care, or protocol that
meets the needs of problem.
4. Actual or construct replication and evaluation of the
policy, standard of care, or protocol.
5. Decision to adopt, alter, or reject the policy, standard
of care, or protocol.
6. Development of means to sustain, disseminate, and
extend the innovation to other settings.
Step 1. Identification of a clinical problem and assessment
of the clinical, theoretical, and empirical evidence for potential
translation. Improving the clinical environment by translating
research on nurse-nurse handoffs into practice at the
bedside was recognized as a need in the hospital.
Assessment of Clinical Evidence
Prior to this project, nurses identified that the method
of shift-to-shift handoffs at the study site was inconsistent
with no hospital-wide standard format for nurse-nurse
handoffs. This posed a particular problem for those nurses
who float from unit to unit and were expected to use whatever
format was operational on each unit of the hospital.
With nurses questioning the feasibility and usefulness of
various methods, there was also no data on the timeliness
or cost related to overtime for the multiple methods of shift
report at the study site.
The types of formats used at the hospital included verbal
reporting, audio-taped in combination with verbal, and
in others, a rounding format. On one unit, a new hybrid
method had been initiated which was a semi-silent report
format based upon computer-generated documentation. A
nurse-satisfaction survey was conducted by a staff nurse
on this unit before and 6 months after the change to semisilent
report. Survey findings suggested that the silent,
computer-generated report format resulted in a negative
impact on team functioning with 74% of the nurses reporting
worsened overall team functioning. Also, 47% of
nurses reported a negative impact on the student or graduate
nurse experience when the silent computer-generated
report was used on that unit (Taft 2006). In addition to
Taft’s survey hospital scores on related NDNQI measures
were examined. Two nurse-satisfaction outcomes including
satisfaction with nurse-to-nurse interactions, and satisfaction
with teamwork among nursing staff were at a high
level. However participation in decision-making and time
for patient care were in the moderate levels with T-scores
at 51.54 and 51.18 levels as compared with other magnet
hospitals of similar bed-size.
It was also noted that at the study site, Press-Ganey
scores on patient satisfaction with variables believed to
be associated with nurses’, shift handoffs had all declined
slightly over the past year. Patient satisfaction outcome
results for items related to how well the nurses kept patients
informed, how well staff worked together to care
for patients, with staff efforts to include patients in decisions,
staff concerns for privacy, and patient’s perceptions
of safety and security while in the hospital were 87.6; 91.1;
88.0; 89.7; and 91.8, respectively. Each of these scores
represented a slight decline from the previous 3 month
reporting cycle, although they still remained above the national
mean.
Assessment of Theoretical Evidence
In addition to the CRU model with its underpinnings
of Roger’s Adoption of Innovations Theory to frame the
overall translational research project, Orlando’s Nursing
Theory was used as theoretical evidence to support
change to a standardized format that recognizes
the immediate needs of patients, and is patient-centered.
Orlando’s theory is congruent with the philosophy of
Nursing at the hospital, which draws from the works
of Henderson (1991), Orlando (1990), and Watson
(1988). Effective communication has been embraced by
Newport Hospital in a “back to basics” approach to
professional nursing practice and is in alignment with
62 Second Quarter 2010 Worldviews on Evidence-Based Nursing
Protocol for Nurse-to-Nurse Handoffs
Orlando’s theory of meeting the immediate needs of patients
and supporting the concept of nursing’s role as a
patient/family advocate.
Orlando’s theory focuses on the deliberative nursing
process (Orlando 1990). As described by Schmieding
(2006), Orlando views the role of the nurse as finding
out and meeting the patient’s immediate need for help.
Nurses use their perception, thoughts about their perception,
or the emotions elicited to explore with patients the
meaning of their behavior. Using this process assists the
nurse in eliciting the nature of the problem and identifying
what help is needed for the patient. According to
Schmieding, “the use of her theory keeps the nurse’s focus
on the patient” (Schmieding 1986, p. 1), thus making it
especially suitable for application to the process of nursing
handoffs.When applying Orlando’s theory, the nurse identifies
her own perceptions, thoughts, and feelings about the
patient’s behaviors as she obtains them from the computerized
rounds report and the nurse reporting off in the
situation, background, assessment, and response (SBAR)
portion of the process. She then validates them with the
patient during the bedside component of the shift handoff.
Deliberative nursing actions to meet immediate patient
needs for the next 8 hours are the next step. Last, she verifies
with the patient whether or not she met his needs, and
determines if further action is needed when she prepares
her summary as the off-going nurse at the end of her shift.
Specific examples of the application of Orlando’s theory
to the specific components of the protocol are listed in
Table 1.
Assessment of Empirical Evidence
To assess the body of empirical evidence, literature
searches were conducted from 1992 to 2009 in the Medline
(via Pub-Med), CINAHL, and Cochrane Database of
Systematic Reviews using the search terms of shift report,
handoffs, handovers, end-of-shift report, nurse-tonurse
report, bedside shift report, computerized report,
and silent report. ERIC was also searched in the understanding
that teaching students the technique of shift handoffs
is an important role of nurses, and may have been
reported in the literature. In addition, resources gathered
from a teleconference sponsored by Healthcare Pro (2006)
and Holly (2006) at the 2006 Eastern Nursing Research
Conference helped to identify other potential sources of
evidence. References from previous literature reviews on
this subject were manually searched and it was found that
this search was inclusive. Using specific inclusion criteria
for appraisal, 40 abstracts were screened. Articles were
included that were qualitative and quantitative studies as
well as the gray literature that specifically described processes
and interventions for shift-to-shift report by nurses
that could be replicated. Full text articles of all 40 abstracts
were retrieved for closer screening by a doctoral
nursing student at the university. Only one randomized
study had been published on this topic, and most studies
were descriptive and qualitative in design. Consequently,
no meta-analyses were available on the subject. In addition
to the studies found in the search, one unpublished
meta-synthesis was also found (Holly 2006) as reported at
the 2006 Eastern Nursing Research Society Conference, in
addition to the study conducted by Taft (2006) at the hospital.
The 42 studies were critiqued in depth for methodological
strengths and weaknesses. An evidence summary
table detailing each study’s reference and country of origin,
study objectives, sampling and type, design, and major
findings. In addition, c
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