Shifting norms: Communication strategies during hospital shift changes

Shift changes can be a scary time for a hospital patient. The nurse they’ve gotten to know, who has taken care of them for the last 12 hours is leaving, and a stranger is taking over.

This hand-off of care is also one of the most difficult parts of the day, and poor communication between the two providers can lead to devastating outcomes for the patient. According to one study, 11 percent of preventable adverse events leading to permanent disability were caused by communication failures.

Luckily this fact has been well recognized, and a great deal of effort has gone into making the transition as smooth as possible.

“It’s a whole different world than when I started as a nurse nearly 20 years ago,” said Rebecca Burns, DNP, MSN, RN, clinical assistant professor at the Texas A&M Health Science Center College of Nursing. Back then, nurses going off shift would speak into a tape recorder any pertinent information about their patients, and then the nurses taking over would listen to the recordings to learn about the people they would be caring for. “This doesn’t allow for a lot of back-and-forth, and makes it difficult to ask questions,” she said. “Now, we communicate with the nurse on the next shift face-to-face.”

Where that conversation happens still varies hospital-to-hospital, though. Some now discuss right at the patient’s bedside. “There are definitely pros and cons to this approach,” Burns said. “It’s great to get the patient involved in their own care, which this method helps facilitate. However, often shift change occurs when patients are sleeping, and you don’t want to disturb them.” Patients recovering in the hospital need their rest, and a common complaint is that they are awoken too many times during the night. Nurses whispering at the patient’s bedside isn’t a great solution either—details can too easily be misunderstood when conveyed at that volume. “Also, occasionally there are things you can’t share with the patient’s family,” Burns said, “and so when there are family members in the room with the patient, the nurses have to go out of the room to discuss those issues. Still, overall I think it’s a good, patient-centered approach.”

The Joint Commission on Transforming Healthcare, which accredits more than 20,500 health care organizations around the country, has guidelines for what they call “hand-off communications.” They advocate a SHARE approach, in which hospitals standardize critical content, hardwire within their system, allow opportunity to ask questions, reinforce quality and measurement, and educate and coach. Another popular method, and the one included as part of the Team Strategies & Tools to Enhance Performance and Patient Safety, is called the SBAR, in which the person going off duty provides a report on the situation, goes over the background, provides an assessment from head to toe of the patient, and finishes with recommendations for the coming shift and any requests.

At the Texas A&M College of Nursing, students are taught a variation of the SBAR called the ISBAR, in which the person providing the report must first introduce themselves to the person they’re communicating with, since staffing is such that the two nurses handing off patient care may not know one another. “From the first nursing course to the final one before graduation, our students study communication and specific techniques to communicate with patients and families, other health team members and especially nursing staff,” said Sharon A. Wilkerson, PhD, RN, CNE, ANEF, dean of the Texas A&M College of Nursing. “They are able to use these techniques in simulated settings as well as in practice in the hospital.”

“I hear from nursing directors where our graduates are employed that our former students understand the importance of accurate and timely communication,” Wilkerson added.

Whatever system a hospital adopts, there is one main goal of the interaction. “The important thing is to get the right information at the right time to the right person,” Burns said. “We’re here to save lives, and good communication is a big part of that.”