ISBARR
The purpose of this project is to practice formulating and delivering patient report to other health professionals using the ISBARR format
Instructions:
1. Find an article on ISBARR (SBAR), summarize, and reflect on how it can be used in communicating assessment findings. Summarize your research on ISBARR/SBAR and cite your reference/s in no less than 500 words
[Nursing Reports 2019; 9:8041] [page 1]
A quantitative study on
personnel’s experiences
with patient handovers
between the operating room
and the postoperative
anesthesia care unit before
and after the implementation
of a structured communication
tool
Ann-Chatrin Leonardsen,
Ellen Klavestad Moen, Gro Karlsøen,
Trine Hovland
Østfold Hospital Trust, Norway
Abstract
Postoperative handover of patients has
been described as a complex work process
challenged by interruptions, time pressure
and a lack of supporting framework. The
purpose of this study was to investigate
involved personnel’s experiences with the
quality of patient handovers between the
operating room and the postoperative anes-
thesia care unit (PACU) before and after
implementation of a structured tool for
communication. The study was conducted
in a hospital in South-eastern Norway.
Personnel completed a questionnaire before
(n=116) and after (n=90) implementation of
the Identification-Situation-Assessment-
Recommendations (ISBAR)- tool. Analysis
included summative statistics, t-tests and
generalized linear regression analysis.
Statistical significance assumed at P<0.05.
The overall impression of quality in
handovers improved significantly after
implementation of the ISBAR (P=0.001).
Personnel’s experiences were improved in
relation to that handovers followed a logical
structure, available documentation was
used and all relevant information was com-
municated (P<0.001). Moreover, personnel
found it easier to establish contact at the
beginning of the handover, ambiguities
were resolved and documentation was more
complete (P=0.001). Profession was associ-
ated with seven of the statements, relating
to whether relevant information is clearly
communicated, whether possible risks and
complications are discussed, contact easily
established, and to completeness of docu-
mentation and information. In addition,
findings indicate significantly more nega-
tive experiences among receiving personnel
both pre- and post-implementation.
Implementation of a structured tool for
communication in patient handovers, may
improve quality and safety in patient han-
dovers between the operating room and the
PACU. Research is needed to define opti-
mal patient handovers and to determine the
effect of handover quality on patient out-
comes.
Introduction
The risks associated with perioperative
care and anesthesia do not end when the
patient leaves the operating room- the
potential for complications continues dur-
ing the patient transfer to the postoperative
anesthesia care unit (PACU).1 In the PACU,
patient care is transferred from the Nurse
Anesthetist (NA)/Anesthesiologist/Surgical
Nurse (SN) to a PACU Registered Nurse
(RN) or Critical Care Nurse (CCN). The
handover is usually completed at the
patient’s bedside, with the NA/SN verbally
reporting to the RN/CCN. The handover
includes the exchange of essential medical
information, which occurs throughout all
phases of care, and is at risk of degradation
and miscommunication.2 During the recov-
ery period, the patient is at risk of potential
complications after surgery or anesthesia.
Furthermore, patients are often subject to a
downscale in monitoring and observation,
which makes them vulnerable to incidents
and errors.1,3,4 Postoperative handover of
patients have been described as a complex
work process challenged by interruptions,
time pressure and a lack of supporting
framework.3
According to the Joint Commission
approximately 80% of medical errors are
due to communication failure during the
patient transfer process.5 Nagpal et al.6
found that o
nly
55.8% of all relevant infor-
mation is transferred from the operating
room to the PACU. Moreover, studies have
shown that the verbal information transfer
are unstructured, and that important infor-
mation is omitted.7,8 Poor communication
and incomplete transfer of information may
threaten patient safety, and may lead to
unplanned readmissions and adverse
events.9,10
Studies suggest that the use of a check-
list during handovers could help providers
correctly exchange information and
increase the adequacy for nurse receivers.1
The Situation, Background, Assessment and
Recommendation (SBAR) tool has become
the Joint Commission’s suggested best
practice for standardized communication in
healthcare, structuring critical verbal infor-
mation, and is also recommended by the
World Health Organization (WHO).11 The
Identification-Situation-Background-
Assessment-Recommendation (ISBAR) – a
variant of the SBAR – is utilized in hospi-
tals, e.g. in Denmark and Australia.12-14
Recent studies have mainly been con-
ducted on handovers between e.g. ambu-
lance personnel and the emergency depart-
ment, from specialist- to primary healthcare
services or between in-hospital personnel
shifts.15,16 A systematic review of the litera-
ture found 31 studies examining postopera-
tive handoffs.4 Of these, only four studies
included an intervention to improve the
process.
Aims
The study was grounded in feedback
from PACU nurses that the quality of
patient handovers needed improvement,
especially related to transfer of sufficient
and critical information. Consequently, the
study aims were: i) to investigate the per-
sonnel’s experiences with the quality of
patient handovers between the operating
room and the PACU before and after imple-
mentation of a tool aiming at improving
communication during patient handovers
(the ISBAR); ii) to investigate whether
there were different experiences with
patient handover quality among transferring
and receiving personnel; iii) to investigate
whether factors such as gender, age, profes-
sional background and years of experience
were associated with these experiences.
Nursing Reports 2019; volume 9:8041
Correspondence: Ann-Chatrin Leonardsen,
Østfold Hospital Trust, Kalnesveien 300, 1714
Grålum, Norway.
E-mail: ann.c.leonardsen@hiof.no
Key words: Personnel’s experiences; patient
handovers; postoperative anesthesia care unit;
quantitative study.
Contributions: all authors contributed in plan-
ning of the study, data collection, analysis and
writing.
Conflict of interest: the authors declare no
potential conflict of interest.
Funding: funding was granted by collabora-
tion funds from Østfold Hospital
Trust/Østfold University College.
Received for publication: 18 January 2019.
Revision received: 12 March 2019.
Accepted for publication: 13 March 2019.
This work is licensed under a Creative
Commons Attribution NonCommercial 4.0
License (CC BY-NC 4.0).
©Copyright A-C. Leonardsen et al., 2019
Licensee PAGEPress, Italy
Nursing Reports 2019; 9:8041
doi:10.4081/nursrep.2019.8041
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Materials and Methods
The study had a cross-sectional, quanti-
tative design, with two points of measure-
ment, using a questionnaire to investigate
personnel’s experiences with patient han-
dovers.
Setting and participants
The study was conducted in a hospital
in a county in South-eastern part of Norway,
which has a catchment area of approximate-
ly 290,000 inhabitants. The surgical ward in
the hospital conducts about 8000 acute or
elective surgical interventions each year,
distributed on different specialties; gas-
troenterology, gynaecology, endocrinology,
mammae surgery, urology, orthopedics,
ear/nose/throat- and vascular surgery, as
well as trauma surgery. The PACU is locat-
ed in immediate proximity to the operating
room.
A consecutive sampling method was
used: All the NAs, anesthesiologists, SNs,
RNs and CCNs involved in patient han-
dovers were invited to participate in a ques-
tionnaire study before and after implemen-
tation of the ISBAR tool. Table 1 gives an
overview of respondents’ professional
background, age and years of experience
pre- and post-implementation (Table 1).
There were significant differences in gender
pre- and post implementation, with 75.7%
female pre-, and 87.4% post-implementa-
tion (P<0.001). Only one anesthesiologist
responded to the questionnaire (pre-inter-
vention), and has been excluded from the
analysis.
Procedure
The operating room and PACU person-
nel were informed about the study aims and
procedures during professional meetings. In
addition, all personnel received email infor-
mation, and information was included in
weekly newsletters sent out by leaders in
the respective wards.
Questionnaires were printed out in
paper and delivered to all personnel directly
involved in patient handovers. Completed
questionnaires were returned in a sealed
box in a room at each ward, and collected
by researchers once a week. Reminders to
complete the questionnaire were sent out
twice by email, to all of the invited person-
nel, before end of data collection.
The pre-implementation questionnaire
study was conducted over three weeks, in
January 2017. The questionnaire study was
repeated six months after implementation,
in November 2017.
Implementation
The implementation of the ISBAR tool
was conducted in three phases.
Development and local adjustment
The ISBAR tool was based on the trans-
lated version implemented in
Rikshospitalet, Oslo University Hospital,
and locally adapted by the research group,
which consisted of one NA, one SN, one
CCN as well as the project leader/first
author, also NA. Before implementation,
the ISBAR was sent out to five NAs, five
SNs and five CCNs respectively, to test the
face- and content validity of the tool,
assessing the adequacy, appropriateness and
understandability of the tool as well as lan-
guage and usage instructions.17 This
revealed no problematic issues in any of
these aspects.
Education of involved personnel
Coursing was conducted by members of
the research group during personnel meet-
ings, as well as through information distrib-
uted by email.
Implementation (April 2017)
This included information to leaders as
well as surgeons which could possibly be
affected by the process, due to a potentially
longer handover time. Moreover, a resource
group with CCNs was established, taking
part in patient handovers the two first weeks
of the implementation, in addition to mem-
bers from the research group.
The questionnaire
A handover quality rating form (HQRF)
developed by Manser et al.,18,19 and translat-
ed to Norwegian by Reine et al.20 (the N-
HQRF) was used. The questionnaire
includes three factors predicting handover
quality: information transfer, shared under-
standing and working atmosphere. The N-
HQRF consists of 19 statements. Response
alternatives are agree, partly agree, partly
disagree and disagree. Since the question-
naire was adjusted to our purpose, we chose
to conduct a repeated test of face- and con-
tent validity as described with the ISBAR
(piloted to 5 NAs, 5 SNs, 5 CCNs), reveal-
ing no problematic issues related to adequa-
cy, appropriateness and understandability of
the tool, as well as language.
The questionnaire also included infor-
mation about professional background,
years of experience from the current ward
(0-2, 3-5, 6-9, 10 or more), gender and age.
The post-intervention questionnaire
also included a question whether ISBAR
was used in patient handovers, and whether
the respondent perceived that using the
ISBAR has led to safer and higher quality
patient handover.
Internal consistency of the N-HQRF
was assessed by Cronbach’s alpha=0.7,
which is assumed acceptable.21
Analysis
Data was analyzed using the Statistical
Package for the Social Sciences (SPSS) ver-
sion 24 (IBM Corporation, IBM SPSS
Statistics for Windows, Version 21.0. New
York, Armonk, 2012).
Answers were dichotomized into either
positive or negative experiences: Agree and
partly agree were collated, as well as dis-
agree and partly disagree. Summative
statistics were used to present characteris-
tics of the sample. T-tests were used to pre-
sent differences pre- and post-implementa-
tion and between personnel. A generalized
linear regression model using profession,
age, gender and years of experience as inde-
pendent variables, and each statement as
dependent variables was used to detect fac-
tors associated with experiences.
Significance was assumed at P<0.05.
Ethical considerations
The Regional Committee for Medical
and Health Research Ethics in Norway
judged the study as quality improvement
(ref. no. 2016/2104A). Approval was sought
and received from the Norwegian Social
Sciences Data Services (ref. no. 51479).
The study was based on the principles in
the declaration of Helsinki,22 on voluntary
participation, anonymity, and confidentiali-
ty. It is not possible to recognize any of the
respondents in the study results. Consent
was assumed when respondents completed
and returned the questionnaire.
Results
As described in Table 1, there were no
significant differences between the transfer-
ring and receiving ward in the pre- and post-
implementation study regarding age or
years of experience.
Comparison of pre- and post-inter-
vention responses
Significant differences on the question-
naire statements pre- and post- implementa-
tion of the ISBAR are presented in Table 2.
Table 2 shows that the overall impres-
sion of quality in handovers improved sig-
nificantly (P=0.001). Personnel’s experi-
ences were improved in relation to that han-
dovers followed a logical structure, avail-
able documentation was used and all rele-
vant information was communicated
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(P<0.001). Moreover, personnel found it easier to establish contact at the beginning of the handover, ambiguities were resolved and documentation was more complete (P=0.001).
Differences between personnel pre-
and post-implementation
Table 3 gives an overview of significant
differences between transferring and receiv-
ing nurses pre- and post-implementation
(Table 3).
Table 3 shows that receiving nurses had
significantly more negative experiences on
six of the statements, related to complete-
ness of information and utilization of avail-
able documentation. Transferring nurses
experienced to a larger extent that it was
difficult to establish contact at the begin-
ning of handovers.
Experiences with the ISBAR tool
Approximately 91% of transferring per-
sonnel claimed to be using the ISBAR in
patient handovers, and this was supported
by 96.7% of receiving personnel stating that
the transferring personnel used the ISBAR.
The effect of using the ISBAR was indicat-
ed through that 92.1% stated that ISBAR
had led to a better and safer patient han-
dover. Nevertheless, 13.6% claimed that
ISBAR did not have any effect on patient
safety or quality in patient handovers.
Factors impacting the experiences
Few significant associations were iden-
tified. The statement The person handling
over the patient is under time pressure was
negatively associated with years of experi-
ence (P=0.008).
Profession was associated with seven of
the statements; namely All relevant infor-
mation is selected and communicated
(Beta=0.06 (Standard Error (SE)=0.03),
R2=0.07, P=0.02), The person handling
over the patient communicate her/his
assessment of the patient clearly
(Beta=0.09 (SE=0.03), R2=0.08, P=0.04),
Possible risks and complications are dis-
cussed (Beta=0.12 (SE=0.03), R2=0.09,
P<0.001), It is easy to establish good con-
tact at the beginning of a handover (Beta=-
Article
Table 1. Respondents’ professional background, age and years of experience pre- and
post- implementation.
Pre (n=116) Post (n=90) P-value
Transferring NA 62.5 25 0.65
SN 42.4 45
Receiving CCN/RN 63.6 50.5
Age (mean) 48.0 47.4 0.94
Experience (years) 0-2 14.7 0-2 10 0.73
3-9 31 3-9 34.4
10+ 53.4 10+ 55.6
NA, nurse anesthetist; SN, surgical nurse; CCN, critical care nurse. RN, registered nurse. Proportion of the population in percentage.
Transferring: transferring ward – the operating personnel room. Receiving: receiving ward – the postoperative anesthesia care unit personnel.
Experience: respondents’ work experience from current ward, in years, reported in percent. Significance level, P<0.05. Independent samples
t-test, equal variances assumed.
Table 2. Significant differences pre- and post- implementation.
Statement Pre (n=116) Post (n=90) P-value
Often/Agree Seldom/Disagree Often/Agree Seldom/Disagree
The person taking over the responsibility is under time pressure 69.7 30.3 60.5 39.5 0.01
The handover followed a logical structure 81.2 18.8 97.8 2.2 <0.001
The person handling over the patient continuously used available 47 57.3 85.7 14.3 <0.001
documentation to structure the handover
All relevant information is selected and communicated 87.6 12.4 97.8 2.2 <0.001
It is easy to establish good contact at the beginning of a handover 81.2 18.8 89.1 10.9 0.001
Questions and ambiguities are resolved 87.8 12.2 95.6 4.4 <0.001
The team jointly assure that the handover is complete 53.8 46.2 73.3 26.7 <0.001
Documentation is complete 73.3 26.7 91 9 <0.001
The patients’ experience is considered carefully during handover 69 31 77.3 22.7 0.007
Overall, the quality of the handovers is very high 82.6 17.4 93.3 6.7 <0.001
Proportion of responses in percent. Significance level, P<0.05. Independent samples t-test, equal variances assumed.
Table 3. Significant differences between transferring and receiving personnel pre- and post implementation.
Pre Post
Statement Transferring Receiving P-value Transferring Receiving P-value
Available documentation used for structure 2.4 (0.09) 2.7 (0.08) 0.01 – – –
Relevant information communicated 1.8 (0.07) 2.1 (0.06) <0.01 1.8 (0.06) 2.0 (0.05) 0.04
Possible risks discussed 2.2 (0.09) 2.6 (0.07) <0.01 2.2 (0.08) 2.6 (0.08) <0.001
Easy to establish contact 2.3 (0.08) 2.1 (0.03) 0.03 2.1 (0.1) 1.9 (0.06) 0.04
Documentation complete 1.8 (.07) 2.5 (0.06) <0.01 1.9 (0.07) 2.1 (0.05) 0.001
Too much information 2.9 (0.07) 3.2 (0.06) <0.01 - - -
Overall, the quality of the handovers is very high 2.0 (0.07) 2.2 (0.06) 0.03 - - -
Attempts are made to minimize interruptions - - - 2.5 (0.1) 2.2 (0.06) 0.03
Responses in mean, standard error in parenthesis. 1=always, 2=often, 3=seldom, 4=never. Significance level, P<0.05. Independent samples t-test, equal variances assumed.
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0.05 (SE=0.02), R2=0.05, P=0.045),
Documentation is complete (Beta=0.12
(SE=0.03), R2=0.09, P<0.001), There is too
much information given (Beta=0.09
(SE=0.03), R2=0.08, P=0.001), and Too
much information is asked for (Beta=0.09
(SE=0.03), R2=0.07, P=0.001).
Discussion
Results indicate that implementation of
the ISBAR tool in handovers of patients
between the operating room and the PACU
improve quality and safety. Personnel’s
experiences were improved in relation to
that handovers followed a logical structure,
available documentation was used and all
relevant information was communicated
after implementation of the ISBAR tool.
Moreover, personnel found it easier to
establish contact at the beginning of the
handover, ambiguities were resolved and
documentation was more complete.
Receiving personnel reported of more neg-
ative experiences with patient handovers
than transferring personnel.
Results indicate that both transferring
and receiving personnel had more positive
experiences with patient handovers after
implementation of the ISBAR tool. The
experience of overall patient handover qual-
ity increased from 82.6% to 93.3%.
Handovers followed a more logical struc-
ture, available documentation was used and
all relevant information was communicated
after implementation of the ISBAR tool.
This is in line with earlier studies, showing
that standardized handover tools result in
better flow of information, a reduction in
omission of relevant information and an
increase in involved personnel satisfac-
tion.3,6,20,23 In addition, studies have shown a
decrease in number of defects per handoff.23
This aspect was not approached in the cur-
rent study.
Moreover, personnel found it easier to
establish contact at the beginning of the
handover, ambiguities were resolved and
documentation was more complete. This
has also been suggested in studies indicat-
ing that structured communication tools
have a positive effect on teamwork.3,6
Initiating a project focusing on improv-
ing patient handover may have led to an
increased emphasis among personnel. In
addition, the study was grounded on input
from receiving personnel that improvement
was needed. Nevertheless, e.g. Cornell et
al.24 found that using SBAR helped nurses
to be more focused and spend less time dur-
ing handovers. However, Petrovic et al.23
found that the mean duration of handoffs
increased by 2 minutes (P<0.01).23 We did
not include information about the time
aspect in the current study.
Post-implementation findings may have
been affected by other factors, due to the
implementation itself. Implementation sci-
ence literature suggests that there are many
factors that can impede implementation of a
new program, e.g., resources, leadership
support or communication.25,26 During
implementation, more personnel were pres-
ent in the PACU ward, posters with infor-
mation were placed in the ward, leaders
supported the implementation (and ice-
cream was served at the end of the two first
weeks). A study on implementation chal-
lenges showed that communicating with
team members and other areas in the organ-
ization, utilizing information technology
solutions, creative use of staff and flexible
schedules, and obtaining additional
resources are factors that decrease imple-
mentation challenges.27
Moreover, results show that receiving
personnel had more negative experiences
regarding safety and quality of patient han-
dovers. This was related to if available doc-
umentation was used and complete, if rele-
vant information was communicated, and
possible risks discussed. This relation is
also identified in the analysis of factors
associated with personnel’s experiences,
since profession was significantly associat-
ed with seven of the statements. This is in
line with studies showing that transferring
and receiving nurses have different expecta-
tions concerning content and timing of
information, and that transferring nurses
have more positive evaluations of handover
quality compared with the receiving
nurses.7,20,28 Moreover, differences has been
found between health professions in terms
of how effectively they hand over the
patient, and on the awareness of severity of
adverse events relating to poor handovers.28
The explanation to this may be that receiv-
ing personnel is taking over the responsibil-
ity for the patient, and hence have a greater
need to have the total overview of the
patients’ condition.
Limitations
One limitation could be that different
personnel were included in the pre- and
post-implementation phases. Nevertheless,
few significant differences between the two
groups were identified (only gender). The
sample sizes pre- and post-implementation
were also relatively small, and few were
men. The study took place in one hospital
only, hence findings may not be generaliz-
able to other wards and settings.
Moreover, the post-implementation
questionnaire study was conducted only six
months after implementation of the ISBAR.
Studies have shown that the use of check-
lists in healthcare represents challenges
with implementation and compliance,29-31
which has also been shown when imple-
menting the ISBAR.32-34 Results could have
been different if we had conducted the post-
implementation study at a later point.
We did not compare the ISBAR tool
with other approaches to improving patient
handovers, or focus on patient outcomes
such as patient mortality or morbidity. This
would be interesting to include in further
studies of quality and safety in patient han-
dovers between the operating room and the
PACU. It is also possible that the positive
changes was due to the Hawthorne effect.35
Conclusions
Results indicate that implementation of
a structured tool for communication in
patient handovers, such as the ISBAR, may
improve quality and safety in handovers of
patients between the operating room and the
PACU. Moreover, this may positively
impact personnel’s experiences with differ-
ent aspects of the handover, such as team-
work. Innovative research is needed to
define optimal patient handovers and to
determine the effect of handover quality on
patient outcomes.
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