Nursing handoffs and clinical judgments regarding patient risk of deterioration: A mixed-methods study

Aims and objectives: To explore how change-of-shift handoffs relate to nurses' clinical judgments regarding patient risk of deterioration.

Background: The transfer of responsibility for patients' care comes with an exchange of information about their condition during change-of-shift handoff. However, it is unclear how this exchange affects nurses' clinical judgments regarding patient risk of deterioration.

Design: A sequential explanatory mixed-methods study reported according to the STROBE and COREQ guidelines.

Methods: Over four months, 62 nurses from one surgical and two medical units at a single Canadian hospital recorded their handoffs at change-of-shift. After each handoff, the two nurses involved each rated the patient's risk of experiencing cardiac arrest or being transferred to an intensive care unit in the next 24 hours separately. The information shared in handoffs was subjected to content analysis; code frequencies were contrasted per nurses' ratings of patient risk to identify characteristics of information that facilitated or hindered nurses' agreement.

Results: Out of 444 recorded handoffs, there were 125 in which at least one nurse judged that a patient was at risk of deterioration; nurses agreed in 32 cases (25.6%) and disagreed in 93 (74.4%). These handoffs generally included information on abnormal vital signs, breathing problems, chest pain, alteration of mental status, or neurological symptoms. However, the quantity and seriousness of clinical cues, recent transfers from intensive care units, pain without a clear cause, signs of delirium, and nurses' knowledge of patient were found to affect nurses' agreement.

Conclusions: Nurses exchanged more information regarding known indicators of deterioration in handoffs when they judged that patients were at risk. Disagreements most often involved incoming nurses rating patient risk as higher.

Relevance to clinical practice: This study suggests a need to sensitize nurses to the impact of certain cues at report on their colleagues' subsequent clinical judgments. Low levels of agreement between nurses underscore the importance of exchanging impressions regarding the likely evolution of a patient's situation to promote continuity of care.

Keywords: clinical judgment; handoff; mixed-methods research; nursing assessment; patient deterioration.