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不同护理交接方式在确保住院患者信息连续性方面的有效性

Declaraciones de intereses de los autores

Versión publicada: 24 junio 2014 Historial de versiones

https://doi.org/10.1002/14651858.CD009979.pub2
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研究背景

临床信息的准确交接对护理的连续性和安全性非常重要。若未准确及时地交接临床相关信息，则可能会导致不良事件、诊治延误、治疗不当和护理遗漏。在过去十年中，改善交接干预措施的呼声越来越高。这些干预措施旨在降低沟通不畅、误解以及关键信息遗漏的风险。

研究目的

确定旨在改善医院护理交接干预措施的有效性，特别是：

确定哪一种护理交接方式可以改善住院患者的结局，以及哪一种交接方式可以护理治疗过程结局。

检索策略

我们检索了以下电子数据库来获取主要研究：Cochrane EPOC组专业注册库（Cochrane Effective Paractice and Organisation of Care [EPOC] Group specialised register ）（检索日期截至2012年9月19日）、Cochrane对照试验中心注册库（Cochrane Central Register of Controlled Trials, CENTRAL）（截至2013年3月1日）、MEDLINE（1950年至2013年3月1日）OvidSP、EMBASE（1947年至2013年3月1日）OvidSP、CINAHL（护理和联合卫生文献累积索引）（1980年至2013年3月1日）EbscoHost和ISI Web of Knowledge（科学引文索引和社会科学引文索引）（截至2012年7月9日）。我们也检索了效果评价文摘数据库（Database of Abstracts of Reviews of effectiveness, DARE）来筛选相关系统综述。我们筛选了已纳入研究的参考文献列表和相关系统综述。我们还检索了世界卫生组织国际临床试验注册平台（International Clinical Trials Registry Platform, ICTRP）http://www.who.int/ictrp/en/以及目前的对照试验www.controlled-trials.com/mrct，并检索了灰色文献网站。

纳入排除标准

评价医院环境中护士之间任何护理交接方式的随机对照试验（randomised controlled trials, RCT）或整群RCT，试验旨在预防不良事件的发生或者优化连续性护理所需的准确基本信息的传递，或者二者皆有。

资料收集与分析

两名系统综述作者独立评价试验质量并提取资料。

主要结果

检索确定了2178篇引文，其中28篇被认为可能相关。在对这些研究全文进行独立评价后，由于缺乏具有随机对照试验设计的研究，故没有符合条件的研究能够纳入本系统综述。

作者结论

没有证据能够支持关于护理交接方式在确保住院患者信息连续性方面的有效性的结论，因为我们发现没有研究符合本系统综述的方法学标准。因此，仍不确定何为最有效的交接方式。研究工作的重点应该是通过精心设计、严谨的研究来加强关于护理交接方式有效性的证据。根据目前现有的知识，在重新设计护理交接程序时可应用以下指导原则：面对面交流、结构化文档、患者参与并使用IT技术支持该流程。

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

确保住院患者信息连续性的最佳护理交接方式是什么？

什么是护理交接？

当一名护士将护理患者的责任移交给另一名护士时，就会进行护理交接，比如在护理班次结束时。平均而言，每位患者每天要进行三次护理交接。

现在有哪些护理交接方式？

平时的护理交接有许多方式，一些交接是通过护士之间的交谈（口头交接）完成的。其他的交接方式则是通过护士阅读患者的病历或阅读病历与交谈相结合来完成的。在某些情况下，护理交接是在患者床边完成的，以便患者也可以提出意见（如果需要的话）。

为什么需要研究护理交接方式？

当一名护士将护理责任移交给另一位护士时，如果没有彻底且高效地传达所有重要的医疗信息时，就有可能发生失误。未提及或掌握信息可能会延误患者的诊治、治疗不当、或者无法提供适当的护理。因此，准确交接临床信息对于确保护理连续性和患者的安全至关重要。

本系统综述的目的和结果

本系统综述试图确定哪一种护理交接方式最有效。

在2013年3月，本系统综述作者进行了广泛检索以筛选合适的相关研究（随机对照试验），这些研究比较了不同的护理交接方式。然而，他们并未找到任何关于此问题的随机对照试验，所以无法得出结论。此领域迫切需要进一步的研究。

Authors' conclusions

Implications for practice

We found no eligible studies for inclusion in the review and therefore the review question remains unanswered. As a consequence, uncertainty remains about the most effective nursing handover practice and, as previously noted, one can only rely on insights obtained from systematic reviews of studies with simple before‐and‐after designs. Breakdowns in communication are one of the main causes of adverse events (AEs) and an accurate handover of clinical information is of great importance to continuity and safety of care. According to current knowledge, the following guiding principles can be applied when redesigning the nursing handover process: face‐to‐face communication, structured documentation, patient involvement and use of information technology to support the process. When designing and implementing a quality improvement (QI) initiative to improve nursing handover one should consider conducting an evaluation using a robust design, (e.g. an interrupted time series (ITS) or a controlled before‐and‐after (CBA) study) to strengthen the evidence about this topic.

Implications for research

At present, high quality evidence on the effectiveness nursing handover styles for ensuring continuity of information in hospitalised patients is lacking. Researchers wishing to evaluate the effectiveness of different nursing handover styles in hospitalised patients should use well designed rigorous studies. Experimental methods such as (cluster) randomised controlled trials (RCTs) are recommended because they offer protection from the effects of background variation. However their use in QI research may be beyond the capacity of many clinicians and researchers because of difficulty in blinding and concealment of allocation (Rotter 2010; Shojania 2004; Shojania 2005). Another feasible rigorous study design that can correct for the drawbacks of simple before‐and‐after designs is an ITS with at least three data points before and three data points after the intervention and at least two intervention sites (EPOC 2009; Grimshaw 2000; Ramsay 2003). This design conveys the extent of background variation and also indicates the extent to which any trend toward improvement may have been present prior to the intervention. When multiple time points before and after an intervention are not feasible, a reasonable alternative to a time‐series analysis is a CBA study, in which the same before‐and‐after measurements occur in one or more hospitals that did not implement the change of interest but are otherwise comparable (EPOC 2009; Grimshaw 2000; Ramsay 2003). Within these designs interventions to improve nursing handovers, such as bedside handover or structured formats for handover can be compared against usual care (i.e. unstructured handover in the office). Also it appears that there is no one single handover format that is applicable everywhere, the context and local situation are important factors to consider when designing a handover process and structure.

Ideally, when evaluating the effectiveness of nursing handover styles objective outcome measures should be used. Nurse‐sensitive indicators are being proposed as a means of measuring the impact of nursing care quality on patient outcomes. These include preventable AEs such as medication errors and patient falls, or complications such as pressure ulcers and nosocomial infections, as well as length of hospital stay and patient satisfaction (Burston 2013). Process outcomes that can be used include recall of information, compliance with the plan of care, time and interruptions. Since the incidence of AEs is not high, a sufficient number of participants (for RCT designs) or sufficient time interval (for ITS and CBA designs), or both, should be applied.

Background

In its 2001 report, 'Crossing the Quality Chasm' the Institute of Medicine (IOM) stated that handovers provide an opportunity for error and that “in a safe system, information is not lost, inaccessible, or forgotten in transitions” (IOM 2001). In a 2009 hospital survey on patient safety‐culture, hospital staff respondents reported that “important patient care information is often lost during shift changes and patient transfers” (AHRQ 2009). Inadequate and ineffective interpersonal communication between healthcare professionals is an often‐cited key factor contributing to errors and procedural mistakes, which may lead to adverse events (AEs). Breakdowns in communication were implicated as one of the main causes of AEs reported to the Joint Commission in the USA between 2004 and 2010 (Joint Commission 2011). In an Australian study of more than 14,000 admissions, 17% were associated with an AE; in 11% of these communication problems were found to be a contributing factor (Wilson 1995).

Handovers of patient care thus introduce a 'vulnerable gap' that may result in AEs if clinically relevant information is not shared accurately and in a timely manner (Bhabra 2007; Handover Europe 2011; Pothier 2005). Other consequences of a poor handover might be delays in diagnosis or treatment (Joint Commission 2002), inappropriate treatment and omission of care. However, inefficiency due to rework, redundant communications and activities, may result in lower satisfaction for both healthcare provider and patient, increased costs, increased length of hospital stay and more readmissions (Patterson 2010). As a result, it is now well recognised that an accurate handover of clinical information is of great importance to continuity and safety of care.

This review will focus on the nursing handover as an instrument for ensuring continuity of care for hospitalised patients. This specific scope is chosen as nurses are pivotal in ensuring continuity of care in a 24‐hour seven‐days‐a‐week environment, not only since they are present both day and night (Messam 2009), but also because they are seen as a communication partner for all healthcare professionals and are often the (in)formal co‐ordinators of the increasingly complex care that is given within hospitals (IOM 2010). To fulfil this role a complete and up to date picture of the patient's care plan has to be handed over frequently ‐ on average three times a day and two times during each nurse's shift ‐ and, due to frequent part‐time working among nurses, handovers occur between many different nurses. Usually handovers are time‐consuming, lack consistency and are varied in style (Clark 2009; Kerr 2011; Sexton 2004), and nursing handovers are no different. Furthermore, nurses, just like most healthcare professionals, may receive no formal training in the handover process other than by modelling from peers and superiors (Van Eaton 2010). As a consequence, the nursing handover is a vulnerable process with potential to result in AEs, unnecessary duplication of work or sub‐optimal care.

Although the literature so far has not provided a thorough or agreed definition of the concept of handover and its scope, continuity of patient care is its primary function (Sherlock 1995; Thurgood 1995). The distinctive feature that distinguishes a handover from other (in)formal communication about patients is the transfer of professional responsibility for the patient (Cohen 2010). Responsibility deals with the transfer of accountability for the quality, safety and satisfaction of the patient. Within this review we define a handover as the exchange of specific information about a patient from one health professional to another, or from one team of health professionals to another, accompanied by the transfer of responsibility for that patient with the purpose of ensuring the continuity and safety of the patient's care (Cohen 2010; Jeffcott 2009). The scope of this review covers the exchange of information about content (the 'what' aspect), as well as the way, or method, in which it is communicated (the 'how' aspect) (Murphy 2009). Content can be structured (e.g. templates, mnemonics, checklists, or a combination of these) or unstructured. Method refers to the communication methods, e.g. verbal, written or taped. In addition to the content and method, the location (the ‘where’ aspect) of the handover may also differ. Location can be either bedside or office‐based. We define a handover style as any combination of the above‐mentioned characteristics, that is, content ('what'), method ('how') and location ('where') (Kerr 2002; Sexton 2004).

Literature frequently identifies the following nursing handover styles: bedside, verbal, nonverbal and taped (Messam 2009).

  • Bedside: located at the patient’s bedside, which promotes patient and nurse face‐to‐face interaction and encourages patients’ verbal participation, thus making the patient central to the information exchange process (Greaves 1999; Kassean 2005).

  • Verbal: located in an office setting, the nurse responsible for a group of patients exchanges relevant documented information (Bourne 2000; Lally 1999).

  • Non‐verbal: located in an office setting, nurses inform themselves by reading the patient health record, involving progress notes, medication charts, observation charts and nursing care plans (Taylor 2002).

  • Taped: located in an office setting, the nurse in charge collects the relevant information and records this onto an audiotape so that the oncoming shift can listen at a convenient time (Dowding 2001).

During the last decade the call for interventions to improve handovers has increased (AMA 2006; AHRQ 2009; BMA 2005; IOM 2001; Joint Commission 2002; WHO 2006). These interventions aim to reduce the risk of miscommunication, misunderstanding and the omission of critical information, therefore, it is important to find out what constitutes an effective nursing handover style (Patterson 2010; Riesenberg 2010).

Description of the condition

As mentioned above, handovers of patient care may result in AEs if clinically relevant information is not shared accurately and in a timely manner. Other consequences of a less than perfect handover might be delays in treatment and diagnosis, inappropriate treatment and omission of care. However, inefficiency due to rework, redundant communications and redundant activities may also result in lower satisfaction for both healthcare provider and patient, increased costs, increased length of hospital stay and more readmissions.

Description of the intervention

We considered any nursing handover style (‘what’, ‘how’ and ‘where’) between nurses in a hospital setting with the aim of preventing AEs or optimising the transfer of accurate essential information required for continuity of care, or both. This includes:

  • nurses' shift changes on nursing wards providing different levels of care, such as: regular ward‐based care, high‐dependency care and intensive care unit (ICU);

  • nurse‐to‐nurse transfers during a shift to balance workload;

  • nurse‐to‐nurse interdepartmental transfers, such as between nursing wards, from the emergency department (ED) to the nursing ward, from the recovery unit to the nursing ward, from the ICU to the nursing ward or the other way round.

The review does not include:

  • handover from a primary care setting to a hospital setting by a primary care physician or from the ambulance to the ED;

  • handovers across different health professional groups, such as from a physician to a nurse;

  • handovers from hospital to home or to another healthcare facility upon discharge.

How the intervention might work

Generally handover interventions aim to incorporate a tool or routine into practice that implements a standardised approach to the handover, including written information and standardised communication patterns allowing for questions or for information to be read back. Use of the tool or routine is intended to support the exchange or availability of information about the patient (or both) for the next caregiver, resulting in improved continuity of care through:

  • improved recall of information provided;

  • improved compliance with the plan of care;

  • improved patient involvement;

  • timely delivery of the care;

  • a decrease in incongruent information (information given at handover that is different from the actual condition);

  • a decrease in omissions (information that if left out of the handover that could increase inefficiency);

  • a reduction of time spent resolving issues from incomplete communication at handover.

Therefore, an effective and efficient handover style may reduce the number of AEs and inefficiencies resulting from an ineffective handover, and also reduce the amount of time spent on handovers, thereby freeing‐up time that can be spent in direct patient care (Sexton 2004).

Why it is important to do this review

Since handovers have been identified as a primary communication moment, many organisations, institutions and hospitals have initiated quality projects to improve handovers. In the 'High 5s Project', launched by the World Health Organization (WHO) in 2006, one of the five patient safety problems targeted was 'Communication failures during patient handovers' (WHO 2006). Literature on handovers is accumulating and thus it is important to understand the effectiveness of interventions aimed at improving nursing handovers and consequently ensuring continuity of care, as well as preventing AEs. Since the WHO and national government agencies are promoting handover interventions to improve patient safety (WHO 2007), these policy decisions should be based on evidence of the effectiveness of these interventions. There are risks involved in implementing interventions for which evidence of effectiveness is lacking: valuable resources can be wasted and clinicians might become reluctant to implement other measures. The aim of this review is to synthesise the evidence from high‐quality studies in order to determine the most effective nursing handover style.

Objectives

To determine the effectiveness of interventions designed to improve hospital nursing handover, specifically:

to identify which nursing handover style(s) are associated with improved outcomes for patients in the hospital setting and which nursing handover style(s) are associated with improved nursing process outcomes.

Methods

Criteria for considering studies for this review

Types of studies

We considered randomised controlled trials (RCTs or cluster‐RCTs) to be eligible for inclusion (according to the definition of the Cochrane Effective Practice and Organisation of Care (EPOC) Group). We considered published and unpublished studies to be eligible and we imposed no language restrictions.

Types of participants

All patients irrespective of age, gender or condition; and nurses in either general, teaching or university hospitals.

Types of interventions

Any intervention designed to improve nursing handover in a hospital setting compared with a previous or existing hospital nursing handover practice or an alternative intervention as defined by the study. Interventions could target a combination of the content ('what'), communication method ('how') and location ('where') aspects of the handover.

Content could be structured (e.g. including templates, mnemonics or checklists, or a combination of these) or unstructured.

Communication method refers to verbal, written or taped handovers ‐ used individually or in a combination ‐ possibly combined with standardised communication patterns allowing for questions or for information to be read back. Written handovers can be facilitated by either paper‐based or electronic systems.

Location could be either bedside‐ or office‐based.

If at least one of the above‐mentioned characteristics constituted part of a handover style it could be included.

We decided to included comparisons such as:

  • non‐verbal handover in an office setting versus a verbal handover in an office setting;

  • non‐verbal handover based on a structured summary versus non‐verbal handover as in common practice;

  • verbal handover at the bedside versus verbal handover in the office;

  • verbal handover in an office setting based on a structured format versus verbal handover in an office setting based on an unstructured format;

  • verbal handover at the bedside with a standardised communication approach versus verbal handover at the bedside without a standardised communication approach;

  • verbal handover in an office setting using the read back communication principle versus verbal handover in an office setting as in common practice.

If different comparisons were found, these would be taken into account, as long as the intervention targeted one or more of the following characteristics: content (structured, semi‐structured or unstructured), method (e.g. verbal, written and taped) or location of the handover (e.g. bedside or office‐based).

Types of outcome measures

Primary outcomes

  • Patient outcomes: any objective measure for preventable AE (patient safety) measured by, for example:

    • medication errors;

    • complications;

    • sentinel events; or

    • mortality (Patterson 2010).

  • Process of care outcomes (nurse‐related): any objective measure for the transfer of accurate essential information required for continuity of care (Patterson 2010), such as:

    • improved recall of information provided (measured, for example, by number of data points: number correct, number omitted, number incorrect);

    • improved compliance with the plan of care (measured, for example, by adherence indicators);

    • timely delivery of the care (measured, for example, by time difference between planned delivery and actual delivery of care);

    • a decrease in incongruent information (information given at handover that is different from the actual condition);

    • a decrease in omissions (information that could increase inefficiency if left out of the handover).

Secondary outcomes
Efficiency outcomes

  • Time required for handover (either increase or decrease) in relation to the effectiveness of the handover

  • Reduction of time spent resolving issues from incomplete communication at handover

  • Reduction of preventable nursing actions: measured by, for example, double ordering or unnecessary telephone calls

We included any study that reported data for either primary or secondary outcomes.

Search methods for identification of studies

Search strategies for CENTRAL, MEDLINE, EMBASE and CINAHL were developed by a clinical librarian, in consultation with the authors and under the supervision of the Information Specialist and Trials Search Co‐ordinator for the EPOC group. The Database of Abstracts of Reviews (DARE) was searched for related reviews. Searches of CENTRAL, MEDLINE, EMBASE and CINAHL were conducted initially in April 2012. Searches for the Cochrane EPOC Group Specialised Register and ISI web of Knowledge were developed and conducted in July and September 2012 by the Information Specialist and Trials Search Co‐ordinator for the EPOC group. The searches of CENTRAL, MEDLINE, EMBASE and CINAHL were updated through a re‐run in March 2013. All search strategies are provided in Appendices one to six.

Databases

  • Cochrane EPOC Group specialised register (to 19 September 2012) (Appendix 1)

  • Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2013) (to 1 March 2013) (Appendix 2)

  • MEDLINE (1950 to 1 March 2013) OvidSP (Appendix 3)

  • EMBASE (1947 to 1 March 2013) OvidSP (Appendix 4)

  • CINAHL (Cumulative Index to Nursing and Allied Health Literature) (1980 to 1 March 2013) EbscoHost (Appendix 5)

  • ISI Web of Knowledge (Science Citation Index and Social Sciences Citation Index) (to 9 July 2012) (Appendix 6)

The search strategies were comprised of keywords and, when available, controlled vocabulary such as MeSH (Medical Subject Headings). Keywords used included: handover, handoff, change of shift, sign out, and MeSH terms: patient transfer, patient care planning and patient care management. Neither date nor language restrictions were used. All databases were searched from their start dates forward.

Two methodological search filters were used to limit retrieval to appropriate study designs: namely, the Cochrane Highly Sensitive Search Strategy (sensitivity‐ and precision‐maximizing version, 2008 revision) to identify randomised trials (Higgins 2011; section 6.4d); and an EPOC methodology filter to identify non‐RCT designs.

Searching other resources

Grey literature

We conducted a search of the grey literature to identify studies that are not indexed in the databases listed above using the following sources:

  • European handover initiative (URL now inactive Sept, 2021);

  • International WHO Collaborating Centre for Patient Safety Solutions (www.ccforpatientsafety.org/).

The search terms used were: handover, handoff, sign out, shift change, inter shift, transfer.

Trial registries

The search terms used were: handover, handoff, sign out, shift change, inter shift, transfer.

We also:

  • Reviewed reference lists of relevant systematic reviews (Appendix 7).

Data collection and analysis

Data collection and anlaysis is described below. 

Selection of studies

We downloaded all titles and abstracts retrieved by the electronic searching to the reference managing database Reference Manager12. Two review authors (MS and HV) independently screened all titles and abstracts identified through the search strategies to assess which studies met the inclusion criteria. We retrieved and assessed full‐text copies of all papers that were potentially relevant for inclusion. Any disagreement was resolved through discussion between the review authors.

Data extraction and management

We had planned to have two authors independently extract appropriate information regarding the characteristics of each included study, using a data abstraction form based on the EPOC Group template. We intended to extract the following data.

  • Study reference: author name, publication year

  • Study design: RCT or cluster‐RCT

  • Participants: number of participating nurses, age, level of training and years in practice

  • Setting: country, type of hospital, type of department/speciality

  • Intervention: description of the nursing handover intervention, classified according to whether the intervention targets any or a combination of content, method and location of the handover

  • Control: description of control group used

  • Outcomes: measures used to assess patient outcome, process and efficiency outcomes

  • Results: main results of all outcome(s)

Where needed, we planned to contact study authors (if possible) to obtain missing information.

Assessment of risk of bias in included studies

We had planned that eligible studies would be independently assessed on methodological quality using the Cochrane 'Risk of bias' tool, the EPOC Group criteria for randomised controlled trials and the GRADE approach (EPOC 2009; GRADEpro 2010; Higgins 2011). These checklists assess the validity of study design (method of randomisation; allocation concealment; imbalance of outcome measures at baseline; blinding of participants, personnel and outcome assessors; incomplete outcome data; method of data collection; appropriate statistical methods) and the effect and applicability of the results (magnitude of effect; imprecision; inconsistency; indirectness).

Measures of treatment effect

We planned to report pre‐ and post‐intervention proportions (dichotomous outcomes) and means or medians (continuous outcomes) separately. For dichotomous outcomes, such as AEs, we intended to calculate the risk ratio (RR) and the risk difference (RD) together with their respective 95% confidence intervals (CI). For studies reporting continuous outcomes, such as time, we planned to calculate the mean difference (MD) together with a 95% CI. When necessary we intended to contact the first or corresponding author for clarification or additional information. Had authors not reported or supplied data in sufficient detail after we had contacted them, we would have reported the point estimates with 95% CI or a P value, as stated by the author. We would have annotated this with 'as stated by the author'. Where studies reported more than one measure for each endpoint, we planned to abstract the primary measure (as defined in the methods section by the authors of the study) or the median measure identified.

Unit of analysis issues

Clustered studies, where clusters of individuals are randomised (cluster‐RCTs) to intervention groups, but where inference is intended at the level of the individual, need to be analysed appropriately to account for correlation of observations within clusters. Standard statistical methods assume independence of observations, and their use in these types of studies will generally result in artificially small P values and overly narrow 95% CI for the effect estimates (Ukoumunne 1999). We planned to attempt to reanalyse studies with potential unit of analysis errors if information was available about the size/number of clusters and the value of the intra‐cluster correlation coefficient (ICC). If a comparison had been reanalysed, we would have quoted the P value and annotated it as 'reanalysed'. If the ICC was not available we intended to attempt to obtain it by contacting trial authors, or by imputing it using external estimates from similar studies (Ukoumunne 1999), or using general recommendations from empirical research (Campbell 2000). If this had not been possible we would have reported the effect estimate and annotated it with the phrase 'unit of analysis error'.

Dealing with missing data

We intended to contact the authors of included studies for missing data and incorporate this information into the analysis. We would have annotated this information as ‘as provided after contact with the author’.

Assessment of heterogeneity

We expected to find both clinical and statistical heterogeneity due to differences in the types of intervention, types of setting, definition of outcome measures and study design. This made it unlikely that statistical pooling would be feasible, but if there appeared to be a body of studies amenable to meta‐analysis, then we planned to display the results graphically to assess heterogeneity. We would have considered I² statistic values of 50% or greater as indicative of significant heterogeneity. If this had been the case, we would have refrained from pooling and restricted the analysis to a qualitative overview. If there had been sufficient homogeneity in populations, study design and outcome measures (i.e. where I² < 50%) (Higgins 2003), we would have pooled results.

Assessment of reporting biases

We had planned to construct a funnel plot analysis to assess publication bias if there were 10 or more studies included in an analysis. We would have judged that publication bias existed when we detected asymmetry in the funnel plot. We also intended to use the Egger test to assess funnel plot asymmetry (Egger 1997). A thorough search for unpublished studies through searches of the grey literature and contact with known experts in the field would also have assisted in reducing the risk of publication bias. Finally we would have assessed selective outcome reporting bias by comparing either the study protocol (if available) or the methods section (if a protocol was not available) to the reported results of the study.

Data synthesis

A meta‐analysis would have been considered only if we had had two or more studies that were homogeneous regarding population, interventions, comparisons and outcomes. In instances where meta‐analysis would not be possible, we planned to report the results as a descriptive narrative only. For studies that were sufficiently clinically and statistically homogenous (I² < 50%), we planned to use a random‐effects model. Where possible, we would have included both relative and absolute measures of effect in the meta‐analysis. We would have performed data synthesis using Review Manager 5.2 (RevMan 2011). Furthermore we intended to use GRADEprofiler software to assist in the preparation of the ‘Summary of findings’ tables (GRADEpro 2010).

Subgroup analysis and investigation of heterogeneity

Had sufficient data been available, we planned to perform subgroup analyses to compare outcomes for:

  • shift to shift handover on nursing wards providing different levels of care, such as: regular ward‐based care, high dependency care and ICU;

  • interdepartmental handover: from one ward to another ward (same level of care), and between departments with different levels of care: for example from ICU to ward, from recovery to ward, from ward to ICU.

Sensitivity analysis

We planned to perform a sensitivity analysis to explore the impact of the following study characteristics: fixed‐effect versus random‐effects analysis; odds ratios versus risk ratios; and studies with imputed standard deviations versus without imputed standard deviations.

Results

Description of studies

Results of the search

The search identified 2178 citations. Independent examination by the reviewers resulted in retrieval of 28 publications that were potentially eligible for inclusion in the review (Figure 1). After assessment of the full text of these studies, no study was found to meet the inclusion criteria. A description of the retrieved studies and the reasons for their exclusion are presented in the 'Characteristics of excluded studies' section.

Figure 1
Flow diagram of search

Flow diagram of search

Included studies

No eligible studies were found for inclusion in this review.

Excluded studies

Main reason for exclusion was that the studies did not meet the RCT study design: 18 studies used a simple before‐and‐after design (Antonoff 2013; Athwal 2009; Baldwin 1994; Benestante 2008; Chung 2011; Craig 2012; Dean 2012a; Evans 2012; Hussain 2011; Joy 2011; Jukkala 2012; Radtke 2013; Raptis 2009; Stahl 2009; Streitenberger 2011; Thomas 2012; Tucker 2009; Wentworth 2012) three studies were opinion papers (Benaglio 2006; Dean 2012b; Ten Cate 2012), two studies used a qualitative design (Adams 2012; Clair 1969), two studies were editorials (Moore 2012; Rabol 2011,) one study was a simulation study (Dowding 2001), one study performed post implementation evaluation only (Alvarado 2006) and one study was a project description (Aellig 2012). In addition four of the studies were not on nursing handover (Aellig 2012; Antonoff 2013; Dean 2012a; Hussain 2011). The detailed description of retrieved studies and reasons for their exclusion are presented in the 'Characteristics of excluded studies' section.

Risk of bias in included studies

No eligible studies were found for inclusion in this review, so we made no assessment of risk of bias.

Allocation

No eligible studies were found for inclusion in this review, so we made no assessment of selection bias.

Blinding

No eligible studies were found for inclusion in this review, so we made no assessment of performance or detection bias.

Incomplete outcome data

No eligible studies were found for inclusion in this review, so we made no assessment of attrition bias.

Selective reporting

No eligible studies were found for inclusion in this review, so we made no assessment of reporting bias.

Other potential sources of bias

No eligible studies were found for inclusion in this review, so we made no assessment of other sources of bias.

Effects of interventions

No eligible studies were found for inclusion in this review, so we cannot report any effects of interventions.

Discussion

We did not find any randomised studies and could not include any studies that fulfilled our methodological criteria for this review. Therefore, we are unable to draw any conclusions about the effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients. This is disappointing in view of the important role of the nursing handover in continuity of care and the widespread attention the topic receives in light of patient safety. Within the field of physician handover we identified three publications from two randomised studies comparing usual care to an intervention (Lee 1996; Van Eaton 2005; Van Eaton 2010), which indicates that it is possible to apply this design for evaluation of handover styles. One study used a randomised cross‐over design and the other study used randomisation of members to a team. Unfortunately one study was a small study (n = 19) and both studies had a short time frame (three and five months respectively). The outcomes measured were efficiency (workflow and time), continuity of care, safety (adverse events) and self‐reported assessment of the new procedure.

Although no reliable evidence exists yet, there are many examples of researchers attempting to evaluate effectiveness of nursing handover styles in order to improve patient safety and quality of care (listed within the Characteristics of excluded studies). Most of these studies (18 out of 28 studies) were limited to simple before‐and‐after designs of local experiences with quality improvement (QI) initiatives in which the handover practice and how it was performed was described to a varying degree, making reproduction difficult. The handover practice was often evaluated at the level of self‐reported satisfaction (six studies on nurse satisfaction and two on patient satisfaction) and not at the level of effectiveness.

The topic of nursing handover has received considerable attention lately, but the studies designed so far are at a high risk of bias, generate only local knowledge or have not been designed to generate effectiveness data (Glasziou 2011; MRC 2000; Ovretveit 2011; Shojania 2004; Shojania 2005). There is an urgent need for high‐quality studies to provide hospital management with appropriate evidence to guide decisions about the most effective nursing handover style.

Summary of main results

No eligible studies were found for inclusion in this review.

Overall completeness and applicability of evidence

This review is complete, based on the evidence currently available.

Quality of the evidence

No randomised controlled trials were available for inclusion in this review. The majority of the excluded studies were simple before‐and‐after evaluations of local experiences with QI initiatives. The major drawback of this design is a high risk of bias, since there is no control available and changes over time in patient populations, or changes in practice, that are unrelated to the QI intervention may produce the desired improvements (Fan 2010).

Potential biases in the review process

The extensive search strategy was carefully designed and adapted to existing terminology by experienced clinical librarians. We searched a large number of databases and relevant websites. Two review authors independently assessed all potentially eligible titles and abstracts against the eligibility criteria to ensure that no important references were missed. Additionally we searched reference lists of systematic reviews that were identified in the search.

Agreements and disagreements with other studies or reviews

During the inclusion process for primary studies on nursing handover we also identified 27 potential systematic reviews on handover (Appendix 7), six of which could be classified as systematic reviews (Arora 2009; Calleja 2011; Foster 2012; Ong 2011; Riesenberg 2010; Staggers 2013), according to the DARE criteria (NIHR 2013). These reviews had wider inclusion criteria than this review regarding methodology, consisting of QI studies using primarily simple before‐and‐after designs and a wider scope that also included physician or interdisciplinary handover. Searching the references of these reviews revealed no high quality studies we might have missed in our search. Also a recent review by Scott revealed no RCTs, interrupted time series (ITS) or controlled before‐and‐after studies (CBA) (Scott 2012). All the reviews also concluded that the existing literature on patient handovers does not yet support definitive research conclusions, and all addressed the need for high quality studies.

Flow diagram of search

Figuras y tablas -
Figure 1

Flow diagram of search

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