Standardizing the Content of Nursing Shift-To-Shift Report to Improve the Quality of Communication Among Healthcare Providers on an Inpatient Psychiatric Unit

Nurse-to-nurse shift handoffs are highly vulnerable to communication failures that can threaten patient safety and continuity of care. Nurses working in various settings recognize this gap and report low satisfaction with shift handoff communication, but evidence to guide quality improvement initiatives for nursing handoffs is limited. Standardization of the content included in nursing shift handoff is an evidence-based strategy to improve nurses' satisfaction with the quality of handoff communication in general medical settings, but this has not been studied extensively within inpatient psychiatric settings. This study aimed to improve nurses' satisfaction with shift handoff communication on an inpatient psychiatric unit by piloting an electronic shift handoff tool which standardized a minimum set of content to include for each patient during nursing shift handoff. Development of the standardized electronic shift handoff tool was informed by content experts, the best available evidence, and nursing staff working on the unit designated as the site for this study. The shift handoff tool was incorporated into the electronic health record of each patient for a 3-week pilot-testing period. A survey was administered to nursing staff working on the designated unit (N=17) before and after the pilot-testing period. The survey was comprised of 12 questions that measured nurses' satisfaction with 12 elements of shift handoff communication. The questions used a 5-point Likert-scale (1= strongly agree, 2= agree, 3= neutral, 4= disagree, 5= strongly disagree) to measure nurses' satisfaction. Lower scores reflected higher levels of satisfaction. A Wilcoxon Signed Rank Test was conducted to compare pre-& post-intervention survey data for each of the 12 questions. Statistical analysis revealed significantly lower scores for 5 of the 12 elements of shift handoff communication following the pilot-testing period for the standardized electronic shift handoff tool, indicating an increase in nurse satisfaction in these 5 areas (p<0.05). Specifically, nurses reported an increase in satisfaction with the organization of handoff communication (pre-post mean 2.6, 1.9, p=0.015), the consistency in quality of handoff communication (pre-post mean 3.5, 2.7, p=0.02), the amount of background information provided for each patient (pre-post mean 2.5, 1.9, p=0.031), the accessibility of critical patient information in the electronic chart (pre-post mean 2.2, 1.6, p=0.026), and an increase in overall satisfaction with shift handoff practice on this unit (pre-post mean 2.8, 2.1, p=0.008). Nursing staff identified a need for the improvement of shift handoff communication in an inpatient psychiatric setting. Nursing staff reported a statistically significant increase in satisfaction with shift handoff communication after the integration of a shift handoff tool into the electronic health record to standardize critical content to include in shift handoff for each patient. Nurses identified insufficient education and training as a barrier for consistently effective shift handoff communication in this setting.

Running head: STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT Standardizing the Content of Nursing Shift-To-Shift Report to Improve the Quality of Communication Among Healthcare Providers on an Inpatient Psychiatric Unit Julie Fitzwilliam The University of Utah College of Nursing 1 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 2 Abstract Introduction: Nurse-to-nurse shift handoffs are highly vulnerable to communication failures that can threaten patient safety and continuity of care. Nurses working in various settings recognize this gap and report low satisfaction with shift handoff communication, but evidence to guide quality improvement initiatives for nursing handoffs is limited. Standardization of the content included in nursing shift handoff is an evidence-based strategy to improve nurses' satisfaction with the quality of handoff communication in general medical settings, but this has not been studied extensively within inpatient psychiatric settings. This study aimed to improve nurses' satisfaction with shift handoff communication on an inpatient psychiatric unit by piloting an electronic shift handoff tool which standardized a minimum set of content to include for each patient during nursing shift handoff. Method: Development of the standardized electronic shift handoff tool was informed by content experts, the best available evidence, and nursing staff working on the unit designated as the site for this study. The shift handoff tool was incorporated into the electronic health record of each patient for a 3-week pilot-testing period. A survey was administered to nursing staff working on the designated unit (N=17) before and after the pilot-testing period. The survey was comprised of 12 questions that measured nurses' satisfaction with 12 elements of shift handoff communication. The questions used a 5-point Likert-scale (1= strongly agree, 2= agree, 3= neutral, 4= disagree, 5= strongly disagree) to measure nurses' satisfaction. Lower scores reflected higher levels of satisfaction. A Wilcoxon Signed Rank Test was conducted to compare pre-& post-intervention survey data for each of the 12 questions. Results: Statistical analysis revealed significantly lower scores for 5 of the 12 elements of shift handoff communication following the pilot-testing period for the standardized electronic STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT shift handoff tool, indicating an increase in nurse satisfaction in these 5 areas (p<0.05). Specifically, nurses reported an increase in satisfaction with the organization of handoff communication (pre-post mean 2.6, 1.9, p=0.015), the consistency in quality of handoff communication (pre-post mean 3.5, 2.7, p=0.02), the amount of background information provided for each patient (pre-post mean 2.5, 1.9, p=0.031), the accessibility of critical patient information in the electronic chart (pre-post mean 2.2, 1.6, p=0.026), and an increase in overall satisfaction with shift handoff practice on this unit (pre-post mean 2.8, 2.1, p=0.008). Conclusions: Nursing staff identified a need for the improvement of shift handoff communication in an inpatient psychiatric setting. Nursing staff reported a statistically significant increase in satisfaction with shift handoff communication after the integration of a shift handoff tool into the electronic health record to standardize critical content to include in shift handoff for each patient. Nurses identified insufficient education and training as a barrier for consistently effective shift handoff communication in this setting. 3 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 4 Standardizing the Content of Nursing Shift-To-Shift Report to Improve the Quality of Handoff Communication on an Inpatient Psychiatric Unit Introduction Problem Description Nearly two-thirds of errors in healthcare are attributable to miscommunication occurring between healthcare providers at points of transition in patient care, of which are more commonly known as ‘patient handoffs' (Galatzan & Carrington, 2018). Patient handoff, or the process of transferring care and accountability of a patient from one healthcare provider to another, is a fundamental component of healthcare delivery across all settings and disciplines and is particularly relevant to nurses, who are responsible for the delivery and coordination of an estimated 80% of patient care (Jukkala, James, Autrey, Azuero, & Miltner, 2012; Smeulers & Vermeulen, 2016; Streeter & Harrington, 2017). Nurse-to-nurse handoff occurring at shift-change, or "shift report," is the most frequently occurring form of handoff for nurses and can occur upwards of 6 times a day in an inpatient setting (Cornell, Yates, Townsend-Gervis, Vardaman, 2013; Halm, 2013; Poh, Parasuram, & Kannusamy, 2013). Nursing shift report is a long-standing tradition in the field of nursing, and lays the foundation for safety and continuity of patient care by serving to provide the oncoming nursing team with up-to-date and relevant patient information that will guide practice, facilitate the delivery of seamless patient care, and assist in the prioritization tasks and goals for the upcoming shift (Galatzan & Carrington, 2018; Rushton, 2010). The overall practice and format of nursing shift report has seen little change over the past 20 years despite mounting evidence that the process is highly vulnerable to miscommunications that pose a threat to patient safety (Galatzan & Carrington, 2018). Such miscommunications have been shown to result in STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 5 consequences including treatment omissions or errors, delayed diagnosis, and repeated or missed testing; potentially leading to extended hospitalizations, increased costs of care, and harm to the patient (Galatzan & Carrington, 2018). Available Knowledge The Joint Commission and World Health Organization have acknowledged the impact of ineffective handoff communication, which has led to an upsurge in research over the last several decades dedicated to exploring limitations in nursing shift handoff practice and identifying possible strategies for its improvement (Lockwood, 2016; Riesenberg, Leitzsch, & Cunningham, 2010; Smeulers, Lucas, & Vermeulen, 2014). There is insufficient evidence at this time to inform a universal best practice standard for nursing shift report, but research consistently supports standardizing the content and overall structure of shift report as a strategy to improve the consistency and quality of handoff communication (Galatzan & Carrington, 2018). In accordance with these findings, The Joint Commission recently declared standardizing handoff communication as a national safety standard (2006; 2017). The Joint Commission accompanied this announcement with a report outlining specific strategies for healthcare organizations to use in order to improve handoff communication (2017). The recommended strategies included the "standardization of critical content tailored to a specific setting" (The Joint Commission, 2017, pp 3., para 4), and "the standardization of training on how to conduct a successful handoff from the standpoint of the sender and receiver" (The Joint Commission, 2017, pp 4., para 3). Despite this call-to-action, the successful and sustained implementation and integration of standardized handoff tools into practice is highly limited (Riesenberg, Leitzsch, & Cunningham, 2010). Previous studies in nursing research primarily concentrate on standardizing the process and structure of shift report, leading to a paucity of evidence identifying what content is critical STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 6 to include in shift report to facilitate effective handoff communication (Galatzan & Carrington, 2018; Riesenberg, Leitzsch, & Cunningham, 2010; Spooner, Aitken, & Chaboyer, 2018; Yee et al., 2009). Researchers speculate that this gap in handoff research is in part due to the highly specialized nature of modern-day healthcare, resulting in high levels of variation in the content deemed essential to include in nursing shift report from setting to setting (Abraham, Kannampallil, & Patel, 2011; Welsh, Flanagan, & Ebright, 2009). The existing evidence on the content of nursing handoff has shown that nurses working in inpatient medical/surgical settings readily identify the need to improve shift handoff communication, and particularly cite high levels of variation in content included in shift report as a barrier to effective handoff communication (Chung, Davis, Moughrabi, & Gawlinski, 2011; Galatzan & Carrington, 2018; Small, Gist, Souza, Dalton, Magny-Normilus, & David, 2016). In addition, nurses in medical/surgical settings report increased satisfaction with the overall quality and consistency of handoff communication following the implementation of a written or electronic handoff tool that standardizes the content of shift report (Chung, Davis, Moughrabi, & Gawlinski, 2011; Galatzan & Carrington, 2018; Small et al., 2016). Unfortunately, these findings have limited generalizability to other specialty healthcare settings such as inpatient psychiatry (Hunt, Marsden, & O'Connor, 2011). There is a heightened need for research on patient handoff communication within the specialty of inpatient psychiatry, where patients are usually admitted due to severe suicidal ideation or following a suicide attempt and consequently carry a high risk of self-inflicted injury occurring in the hospital (Cowan, Brunero, Luo, Bilton, & Lamont, 2018; Hunt et al., 2011; Millar & Sands, 2013; Poh, Parasuram, & Kannusamy, 2013; Puntil, York, Limandri, Greene, Arauz, & Hobbs, 2013). According to Puntil et al. (2013), "Suicide has repeatedly ranked in the STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 7 top 5 most frequently reviewed sentinel event categories since 1995, and was the 4th most frequently reviewed sentinel event in 2012" (p. 205, para 1). Puntil et al. (2013) also reported that "when analyzing root cause information, assessment and communication were the top two factors contributing to the suicides" (p. 205, para 1). One of the primary roles of nurses working in inpatient psychiatry is to assess and monitor patients to prevent suicidal behaviors in the hospital (Puntil et al., 2013). A comprehensive suicide risk assessment requires historical patient data and information regarding his or her current mental status (Posner, Brown, Stanely, Brent, Yershova, Oquendo, Currier, Melvin, Greenhill, Shen, & Mann, 2011; Puntil et al., 2013). The knowledge nurses require to perform an accurate suicide risk assessment must be communicated effectively between nursing shifts, but unfortunately this rarely occurs in practice (Millar & Sands, 2013). One study on nursing handoff communication in inpatient psychiatry found that, "nursing handovers [in psychiatry] are conducted in an ad hoc manner and may not effectively communicate information that is required for the management of patient risks" (Millar & Sands, 2013, p 345, accessible summary, bullet 2). Millar & Sands further described that the information necessary to formulate an accurate suicide risk assessment was often scattered throughout the medical record, thus limiting its accessibility to staff who wanted to gather additional patient information following shift report (2013). This evidence highlights the urgent need for the identification of best nursing handoff practice in inpatient psychiatry, to promote patient safety through the improvement of nurses' communication of patients' suicide risk factors during shift report (Hunt et al., 2011; Millar & Sands, 2013; Puntil et al., 2013). Rationale The successful and sustained integration of standardized handoff tools into practice is highly limited, and nursing shift report continues to be a highly variable practice that is STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 8 frequently identified as a contributing factor in adverse events (Galatzan & Carrington, 2018; Riesenberg, Leitzsch, & Cunningham, 2010; Yee, Wong, & Turner, 2009). Nurses are hesitant to adopt a new method for handoff procedures without a clear appreciation of the benefit of such a change, or without any personal investment in the venture (Kerr, Lu, McKinlay, & Fuller, 2011; Small et al., 2016). Research has shown that increased usage and adoption of a standardized shift report tool is associated with the involvement of local nurses in the development and implementation of the new protocol or tool (Galatzan & Carrington, 2018) Kotter's change model, initially designed for use in a business setting, provided the conceptual framework to guide the successful implementation and adoption of this quality improvement project (Small et al., 2016). The Kotter change model is unique in that it "recognizes the need to incorporate opinions from staff and other stakeholders," thus creating a vested interest among key stakeholders (Small et al., 2016, pp. 305, para 3). Numerous studies of successful healthcare quality improvement projects demonstrate that this model provides an effective framework to guide the sustainable implementation of a project; therefore, the Kotter change model will guide the development and implementation of this project. The model is comprised of eight successive steps (Kotter, 2012): 1. Create a sense of urgency (Kotter, 2012). This first step initiates the change process by bringing about stakeholder awareness of the problems, and by "highlighting the need to correct a pressing problem" (Small et al., 2016, pp 305, para 5). A sense of urgency and personal relevance is ignited by providing evidence-based education to nursing staff regarding the potential consequences of inadequate handoff communication (Small et al., 2016). Personal buy-in is initiated when individual nurses learn in what ways this overarching problem could directly impact his or her practice of patient care and STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 9 licensure (Small et al., 2016). 2. Form a guiding coalition (Kotter, 2012). A group of peer leaders further enhances individual stakeholder buy-in to the project (Kotter, 2012; Small et al., 2016). 3. Create a vision (Kotter, 2012). When leaders communicate the end-goal of a project, they cultivate a sense of meaning and purpose to the changes being implemented (Kotter, 2012; Small et al., 2016). Nurses are more likely to be on-board with a proposed change when they can identify the rationale, value, and personal benefit behind an organizational change (Small et al., 2016). 4. Communicate the vision (Kotter, 2012). Effectively communicating a vision involves the use of simple language, repetition, and the use of various types of communication modalities such as flyers, meetings, and leading by example (Kotter, 2012). This strategy improves awareness and adoption of the vision among staff (Kotter, 2012; Small et al., 2016). 5. Empower stakeholders (Kotter, 2012). When leaders show that they value nurses' contributions, participation, and input to the project, individual nurses are much more likely to adopt a change (Kotter, 2012; Small et al., 2016). For this reason, it is of the utmost importance to seek out and incorporate feedback from nurses into the final project design to create a sense of individual ownership in the process (Kotter, 2012; Small et al., 2016). 6. Create quick wins (Kotter, 2012). Noticeable results in the short-term improve overall morale and perceived value of the long-term vision of the project (Kotter, 2012; Small et al., 2016). 7. Build on the change (Kotter, 2012). Efforts to address related problems maintain the STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 10 momentum of the original project and continue to promote a healthy sense of urgency (Kotter, 2012). 8. Institutionalize the change (Kotter, 2012). A change can be considered a success when it becomes a shared value and regular occurrence within an organization (Kotter, 2012; Small et al., 2016). Specific Aims The primary aim of this project was to promote patient safety and continuity of care by improving the quality and consistency of content included in nursing shift report occurring in an inpatient psychiatric setting. This project was achieved through the development and implementation of a setting-specific nursing handoff tool that was embedded into the electronic health record, which served to standardize content deemed critical to include in shift report for the specified patient population. The tool was developed based on best available evidence regarding critical patient information for nurses working in an inpatient psychiatric setting, and incorporated feedback and suggestions from local nursing staff with the aim of improving cultural adoption and sustainability of the tool (Kotter, 2012; Millar & Sands, 2013; Puntil et al., 2013; Small et al., 2016). Methods Context The identified site for implementation of this project was a locked inpatient psychiatric unit with the capacity to treat up to 20 adult patients (18+ years); hospitalized due to inability to maintain safety in a less restrictive environment specifically related to suicidal/self-harm ideation. The average length of stay on this unit is 7-10 days, but this number is highly variable depending on the individual patient. Patients on this unit are typically medically stable and move STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 11 about the unit freely in accordance with the daily unit schedule. The daily unit schedule consists of various groups, free time, meal times, visiting hours, and quiet hours at night. Patients are granted certain "privileges" by their treatment team, including off-unit-with-staff for meals at the cafeteria, media room privileges, and privileges to wear their personally-owned clothing rather than the hospital-issued scrubs that each patient must wear immediately following admission to the hospital. The identified site is one of nine locked acute inpatient units comprising an urban academic neuropsychiatric facility. The facility also houses several intensive outpatient programs, a clinical assessment center, receiving center, and the department of psychiatry for the academic institution. Clinical staff employed at this facility include RNs, psychiatric technicians, hospital unit coordinators, licensed clinical social workers, PAs, recreation/expressive therapists, psychologists, pharmacists, pharmacy techs, resident psychiatrists, and attending psychiatrists. The identified unit is staffed 24/7 with 1-3 RNs, one health unit coordinator (HUC), and 1-5+ psychiatric technicians (PTs). Staffing is determined on a daily basis depending on the census and acuity of the unit and consists of a blend of "core" staff members and "float pool" staff members. "Core" staff members work on a single designated "home" unit for each of their shifts, whereas "float pool" staff do not have a designated "home" unit and can be assigned to any unit throughout the hospital for each of their shifts depending on the staffing needs of the individual units. Participants in this study included both core and float RNs and psychiatric technicians, all of whom were full-time employees. Nursing shift-to-shift report occurs at least three times in a 24-hour period on the identified unit for this project. The facility has allotted thirty minutes at the beginning/end of each shift for shift report. This unit is typically remains at full census with 20 patients, allowing STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 12 for an average of 1.5 minutes of shift report allotted for each patient. Shift report takes place in a designated report room in the staff office on the unit, and is delivered to all on-coming staff members by the out-going charge RN either in-person or via an audio recording of report from earlier in the shift. The report room is equipped with a table, chairs, and a computer connected to a large TV monitor display. A staff member will log-in to the electronic health record on this computer, and then displays the electronic Kardex for each patient on the TV monitor as the outgoing charge RN provides a live or previously recorded oral report of historical information and updates for each patient on the unit. The electronic Kardex contains critical information for the hospitalization that is entered by admissions, the attending provider, and the admitting RN. Information displayed on the electronic Kardex that is entered by admissions and/or the attending provider includes: a patient photo, fall risk status, legal status of the admission, demographic information, extensive medical history, allergies, unit activity/privilege orders, safety protocol orders, frequency of vital sign and weight monitoring orders, dietary orders, active lines/drains/airways, nursing communication orders, consult orders, un-resulted lab orders, orders to be acknowledged. Information displayed on the electronic Kardex that is entered by the admitting RN includes: reason for hospitalization comprising of the clinical rationale (danger to others, danger to self, or inability to care for self) and a sentence describing any precipitating event for the hospitalization, and the Kardex "sticky note," which is an editable portion of the Kardex/patient chart that functions as a flexible space for communication of information among clinical staff. Information stored within the Kardex "sticky note" is not an official part of the medical record and is erased from the chart upon patient discharge. The facility housing the identified unit for this project does not provide any formal guidelines for content to include in the "sticky note," and thus what is included in this area varies from unit to unit within the facility. STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 13 On the identified unit for this project, the "sticky note" is unofficially designated to hold contextual information about the patient's admission. The content and formatting greatly vary depending on the RN who admitted the patient due to the lack of official guidelines, and typically the admitting RN will copy/paste his or her admission narrative into this area. After the RN has displayed each electronic Kardex and provided a verbal report on each patient, he or she will allow time for oncoming staff to ask questions/clarify information. RNs do not receive any formal training on how to give shift-to-shift report in this facility. New RNs are trained by their peers, which results in variable content and quality of training for orientees. While there currently is no gold-standard or evidence-based guideline regarding the successful implementation of standardized handoffs to improve patient safety and continuity of care, the best available evidence consistently supports several recommendations regarding the process and content of inpatient nursing shift-to-shift report: 1. Previous studies have recommended that specific content that is to be communicated during shift report must be tailored to the specific setting, as this content is highly variable depending on the type of handoff being given, as well as the unique features of the setting and specific patient population in question (Smeulers & Vermeulen, 2016; Welsh et al., 2010). 2. It is also recommended that units differentiate information to include in report from information to be documented in the medical record and not included in the oral shift report (Millar & Sands, 2013; Welsh et al., 2010). 3. Previous studies recommend communicating content regarding care options, estimates of the patient's prognosis, and contingency plans for potential/anticipated adverse events in addition to background and retroactive information regarding a patient's inpatient clinical STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 14 course as this information is highly relevant to both staff and patient safety, but is often challenging to locate within the electronic medical record and rarely included in nursing handoff (Drach-Zahavy & Hadid, 2015; Millar & Sands, 2013; Puntil et al., 2013). Intervention The intervention identified as the method to potentially improve the quality and consistency of nursing shift-to-shift report for this project was a unit-specific nursing shift handoff tool that would standardize a staff-approved minimum data set of critical content to consistently include in shift report on the designated unit. The investigator used a blended approach of combining the best available evidence on critical content to be included in nursing shift report in inpatient psychiatry along with the input of the local RNs. Previous studies have shown a significantly increased likelihood of successful integration of standardized tools into the shift-to-shift report workflow when the unit nurses are involved in the development of the tool, due to an increased sense of ownership of the tool among the nursing staff who were included in its development (Smeulers & Vermeulen, 2016). Awareness of this quality improvement project and the use of the standardized tool by nursing staff during shift report on this unit was promoted via educational flyers and emails. The educational flyers and emails specifically highlighted the significant impact that ineffective handoff communication has on healthcare costs, patient safety, and staff satisfaction. The educational flyers and emails also outlined the most recent evidence informing possible solutions to improve handoff communication, including the benefits and use of a standardized handoff tool that has been tailored to the needs of the setting in which it is implemented. This project was implemented in four phases: In phase 1 a needs-assessment was conducted on the specified unit. A survey was distributed to both core and float pool staff to STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 15 inform a baseline report regarding staff perception of current shift report practice on this unit, as well as to gather data to inform the development of the intervention. With permission from the authors, a modified version of the Handover Evaluation Scale was used to collect these data (O'Connell, Ockerby, & Hawkins, 2014; O'Connell, Macdonald, & Kelly, 2008). Questions from The Handover Evaluation Scale were modified by the investigator to best fit this project and setting, and feedback from participants and content experts was provided for the questions to ensure appropriateness and understandability of the modifications made to the scale. The survey included a free-response space for participants to make specific suggestions and recommendations for ways in which to improve upon current shift report practice and staff recommendations regarding critical elements to include in a standardized shift report tool. Phase 2 of the study included obtaining feedback from core nursing staff on the identified unit and content experts before the development of the final draft of the tool. Three core daytime charge RNs for the unit met at various times to discuss the development of the intervention and strategies for successful implementation. The charge RNs agreed to pilot a standardized format for the Kardex sticky note due to the unregulated nature of this space in the patient chart. The charge RNs agreed upon a standardized minimum data set of information to include in the sticky note section, which consisted of suicidal and self-injurious behavior occurring within the past 3 months and over the patient's lifetime, severity of suicidal ideation present in the past month, activating events related to the suicidal ideation, patient treatment history, and specific factors that amplify or mitigate the patient's potential risk for suicide (Posner et al., 2011). The format and data set for the Kardex sticky note were based on the Columbia-Suicide Severity Rating Scale risk assessment tool (Posner et al., 2011), which is accepted as the current gold standard for suicide risk assessment tools (Hill, Hatkevich, Kazimi, & Sharp, 2017). The charge STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 16 RNs and content experts for this project agreed that individual patient safety risk is imperative to communicate between nursing shifts in an inpatient psychiatric setting, and that having this information uniformly available for each patient would increase staff accountability in reading this information and thus would potentially free-up time during report to provide an increased amount of verbal information on patient care plans, current clinical status, and contingency plans (Hunt et al., 2011; Millar & Sands, 2013; Welsh et al., 2010). In phase 3, pilot testing of the new Kardex sticky note format was announced via email to core staff members. This email also included an invitation to take an abridged version of the pre-intervention survey of staff perception of shift report, which would be used to measure the effectiveness of the intervention. Admitting RNs were asked to not fill out the Kardex sticky note during the pilot period. The primary investigator updated format of the Kardex sticky note in accordance with the standardized format for each patient on the unit once every 24 hours for 3 weeks to ensure consistency. After pilot testing was completed, phase 4 of the study was conducted. This phase involved administering a post-intervention survey of staff perception of shift report, providing RNs with the standardized format for the Kardex sticky note, and encouraging RNs to continue utilizing this format for the Kardex of newly admitted patients. This communication was all provided via email. Study of the Intervention The impact of the intervention was assessed by comparing paired pre-and-postintervention survey data regarding staff perception of how the content included in shift report affected the quality of handoff communication. Core nursing staff survey data was gathered both STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 17 pre and post-intervention and was used to assess the impact of which the intervention had on nursing staff perception of the quality of shift report communication. Measures The Handover Evaluation Scale (O'Connell, Ockerby, & Hawkins, 2014) was adapted to fit the specific report needs of this setting with permission from the authors. The survey used Likert-scale questions to assess perceptions of shift report. According to O'Connell, Ockerby, & Hawkins, "The Handover Evaluation Scale is a self-report, valid and reliable measurement of the handover process" (2014, pp 569, para 3), and "can be used to identify areas that require education and development in the handover process" (2014, pp 569, para 3). The adapted version of this survey used during the needs assessment phase of this project was used to gather subjective data from core and float staff regarding the perception of the quality of shift report (O'Connell, Ockerby, & Hawkins, 2014). The adapted version of this survey used for gathering pre-post intervention data was used to gather subjective data from core staff only regarding the perception of the quality of shift report (O'Connell, Ockerby, & Hawkins, 2014). The Kardex sticky note of each patient admitted to the identified unit during the testing period was audited daily by the investigator to track compliance with the standardized tool. Analysis Analysis of the data involved the use of descriptive statistics to describe the demographics of both the pre/post survey sample of participants, and the needs-assessment survey sample of participants. Descriptive statistics were used to describe the central tendency of responses to the Likert-scale questions from the needs-assessment survey, and a nonparametric Mann-Whitney U test was performed to compare responses from RNs and psychiatric technicians and also to compare responses from core staff and float staff to measure for STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 18 statistically significant differences in responses on the needs-assessment survey between these various groups (figure 4). A content analysis was performed for the open-ended survey questions. Transcripts were coded. The coded data were then sorted into categories and summarized according to commonly occurring themes (table 1). A nonparametric Wilcoxon signed rank test was performed for each pre/post survey question to measure for change between paired pre-intervention and post-intervention survey scores. Ethical Considerations This study was deemed a non-human subjects research by the University of Utah Institutional Review Board and thus was not required to undergo formal review. Results Nursing staff working on an inpatient psychiatric unit reported a significant increase in satisfaction with shift report practice specifically regarding the organization, consistency, completeness, and overall satisfaction of content included in nursing shift report following the implementation of a unit-specific nursing shift handoff tool to standardize critical content. During phase 1 of this project, participants were asked in-person to complete a survey regarding current staff perceptions of shift-to-shift report and to inform the development of the intervention. A total of 30 participants completed the in-person survey, including 19 psychiatric technicians and 11 nurses. This survey consisted of 6 demographic items, 19 questions, and 2 prompts to provide free-response feedback. Descriptive statistics were used to describe central tendency of participant demographics for this survey (table 2). A Mann-Whitney U test was performed to compare responses based on position and home unit (figure 4; figure 5). There were no statistically significant differences in responses between core staff and float staff (p<0.05). RNs more strongly agreed with the statement, "I view report as an important part of my shift," as STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 19 compared to psych techs (p=0.005). No other differences were found between RNs and psych techs in responses to survey questions (p<0.05). Content analysis of open-ended survey questions identified 3 overall themes in participant responses and various subthemes (table 1). Comments from staff regarding barriers to shift report included environmental factors such as interruptions and low volume on recording devices, but the majority of information was related to unnecessary content of shift report and other communication factors such as subjectivity and disorganization in presentation. Comments from staff regarding facilitators for shift report included a checklist to standardize content included for each patient and the inclusion of prospective data. Critical content suggestions were dominated by prospective data, active problems, and data to inform risk assessment in the hospital. During phases 3 and 4 of this project, core staff participants were asked via email to complete a pre-and post-intervention survey in order to collect demographic data for the sample (table 3), and data on staff perception of the quality of shift report both before (figure 1) and after piloting the intervention (figure 2). The response rate of the pre-intervention survey was (21/23 staff responded) 91.3% (n=21), and the response rate of the post-intervention survey was 81% (n=17) of the participants who had taken the pre-intervention survey. Participants who did not complete both the pre-and post-intervention surveys were excluded from the study, resulting in a final number of 17 participants in this project. Seventeen pre and post nursing staff scores for each survey question were evaluated using the Wilcoxon signed rank test (figure 3). An analysis was performed for each of the 12 survey questions (p<0.05). The analysis showed a statistically significant increase in satisfaction scores for 5/12 survey questions demonstrating an increase in agreement after implementation of the intervention that shift report was more well-organized STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 20 (p=0.015), provided more comprehensive background/historical information for each patient (p=0.031), was more consistent in overall quality from reporter to reporter (p=0.02), if patient information was omitted from report it was more accessible in the electronic health record (p=0.026), and in overall satisfaction with the quality of shift report (p=0.008) (figure 3). Discussion Summary The aim of this study was to improve nursing handoff communication occurring at shift change in a psychiatric setting by developing and integrating a nursing handoff tool into the electronic health record that standardized critical patient data to include in shift report on the identified inpatient psychiatric unit (Hunt et al., 2011; Johnson et al., 2011; Jukkala et al., 2012; Welsh et al., 2010). The project intended to improve the quality and consistency of shift report content specifically required for individual patient safety risk assessment (Posner et al., 2011; Puntil et al., 2013). Development of the intervention was informed by input from local nursing staff to improve acceptance and increase chances for future cultural adoption of the tool (Kotter, 2012; Small et al., 2016; Smeulers & Vermeulen, 2016; Welsh et al., 2010). Data to inform the evaluation for the intervention's effectiveness was measured via an adapted version the Handover Evaluation Scale, which gathered subjective data from nursing staff on perceptions of the quality of shift report (O'Connell et al., 2014). The Handover Evaluation Scale was administered to participants at three intervals during the study. These three intervals included an initial needs assessment, and prior to and after implementation of the intervention. The results of this study demonstrated that after the pilot period of the intervention, there was a statistically significant improvement in nurse perception of shift report in several areas, but STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 21 not in others. Participants reported an improvement in the organization of shift report, felt the quality of shift report was more consistent, felt that any critical information that had been missing from the verbal report was more easily accessible, a more thorough background was provided, and an improvement in overall satisfaction with shift report practice and communication at shift change on this unit (Table 3). Results from the needs assessment survey revealed that RNs were more likely to view shift report as an important part of the shift as compared to nursing support staff (psychiatric technicians). This study reports the first of many cycles in this complex quality improvement initiative to improve nursing shift handoff. This project is one of the few studies investigating strategies to improve the quality and consistency of content transmitted during nursing shift-to-shift report through the implementation of a standardized handoff tool within the electronic health record (Johnson et al., 2011). It is also one of few studies examining interventions to improve the quality and consistency of shift report content in an inpatient psychiatric setting (Cowan et al., 2018; Hunt et al., 2011; Millar & Sands, 2013). Interpretation The findings of this study are consistent with existing literature on nursing perception of shift report (Galatzan & Carrington, 2018; Riesenberg et al., 2010). Nursing staff reported frequently experiencing inconsistencies in the delivery of shift report on this unit, and acknowledged that a standardized minimum data set of critical content to include in shift report was an effective method to improve the overall quality and process of shift report practice and communication (Galatzan & Carrington, 2018; Small et al., 2016). The findings of this study deviated from the existing evidence by showing that despite the recognition of shortcomings in shift report practices, nursing staff had a high level of satisfaction with the quality of shift-to- STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 22 shift report upon baseline assessment (Galatzan & Carrington, 2018; Riesenberg et al., 2010). However, members of nursing staff were able to identify areas where shift report practice could improve and noted that there is an overall lack of guidance for content to be included in shift report on this unit and other units in the same facility. Nursing staff reported an increase in satisfaction with the consistency and organization of shift report with the standardized handoff content tool, which is congruent with the findings in the literature (Galatzan & Carrington, 2018; Johnson et al., 2011; Jukkala et al., 2012). The findings of this study demonstrate that inpatient psychiatric nurses recognize a gap in the quality of nursing handoff communication, and readily identify a need to improve upon current shift report practice to address this gap. The inpatient psychiatric nurses partially attributed inconsistencies in the quality of shift report communication to inadequate education and training on nursing shift handoff, which has previously been identified as a barrier to effective handoff communication in studies on handoff occurring in general medical settings (Galatzan & Carrington, 2018; Kerr et al., 2011; Riesenberg et al., 2010; Smeulers et al., 2014; Welsh et al., 2010). Inadequate education and training could explain in part nurses' reports of inconsistent quality in shift report, as well as the frequent inclusion of unnecessary information and exclusion of pertinent information (Galatzan & Carrington, 2018; Welsh et al., 2010). Nurses' identified a need for guidance in determining which content to include and exclude from shift report and described feeling that they are not being properly trained or supported in development of shift report skills, which is also validated in the literature (Galatzan & Carrington, 2018). A new finding from this study is that nursing support staff (psychiatric technicians) reported the need for a greater proportion of content to be included in shift report that is relevant to all members of the nursing team and not exclusively relevant to the RNs, citing specific examples such as STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 23 medication and lab details. The nursing support staff requested that this information be delivered in a way that would be more meaningful to non-licensed staff, for example including in report what symptoms related to adverse medication effects the patient may complain of as opposed to simply stating the name of a new medication the patient is starting. The results of this study strengthen the existing body of quality improvement research in the area of nursing shift report by incorporating information on content to be communicated during shift report, as well as findings that are from an inpatient psychiatric setting (Hunt et al., 2011; Millar & Sands, 2013; Welsh et al., 2010). Nurses recommended that shift report includes an increased amount of prospective patient information as compared to retrospective information, and the inclusion of care plan and individual nursing interventions to help guide practice and prioritization of tasks on the upcoming shift. Nurses also recommended that shift report includes clear communication of patient safety risks, and agreed that this pertinent information being confined to a known/standardized area of the patient chart increases staff accessibility to and accountability for such information (Puntil et al., 2013; Welsh et al., 2009). Limitations This study had several limitations. The investigator was previously known to the site and participants in this study, which may have affected participants' responses regarding perceptions of shift report during the initial needs assessment and following the pilot-testing of the intervention. Survey responses were submitted anonymously to mitigate risk for such a bias. The survey administered to participants was based on a validated instrument, but adaptations made to the instrument for purposes of this study reduced the instrument's validity (O'Connell et al., 2014). The participants were also informed of the purpose of the study prior to submitting their survey responses, and thus responses may have been biased to favor the perception of the STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 24 intervention. Future studies could implement a design that blinds participants to the purpose of the study until after data collection is complete to address this limitation. The intervention in this study confined the standardized format to a section of the electronic patient chart in a psychiatric unit, which limits the generalizability of the results to other practice settings that may not have an electronic health record or that use an electronic health record that could not accommodate this format. The small convenience sample of nursing staff who participated in the study also limits the strength and generalizability of findings from this study. The specificity of the patient population being treated on the designated unit in this study further limits the generalizability of the findings, as many inpatient psychiatric units are comprised of a broader range of psychiatric diagnoses. Lastly, this project did not include follow-up data required to assess for the sustainability of the intervention, which limits the strength of the findings. This data could be gathered in future QI cycles of this initiative. Conclusions This project provides evidence that implementing a standardized, unit-specific guideline for critical content to include in shift handoff is a feasible and effective strategy to improve nurses' perceived quality of nursing handoff communication in an inpatient psychiatric setting. Nursing staff in this setting specifically reported an improvement in the perceived value and consistency of the information included in shift report following the implementation of this intervention. Suggestions from nursing staff regarding methods to improve shift report were gathered during the initial needs assessment portion of this project, and further exploration of this data is needed to best inform future QI cycles for improving shift report content, practices, and STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 25 education. Specific examples from this data include the incorporation of more content into shift report that is relevant to all members of the nursing team and not exclusively the RNs, as nursing support staff reported viewing the importance of shift report as overall less important as compared to nurses. Nursing staff consistently suggested the development of a content checklist for shift report would aid in consistency of report and improve memory recall when giving report. Other changes recommended by nursing staff indicated that information regarding patients' level of risk is necessary to facilitate early identification of and thus earlier implementation of interventions for higher risk patients, and would like to see this information always included in shift report. Lastly, Nursing staff also expressed a desire for improved communication regarding specific treatment plan and nursing interventions to improve continuity of care and patient satisfaction. Future QI cycles could inform the development of any of such interventions. This study has great implications concerning current training and education of nurses regarding handoff practices. Nurses do not feel confident in their ability to give report and are not satisfied with the current level of training provided on giving shift report in this facility. Quality improvement interventions at this level may reduce inconsistencies in the content and quality of shift report and increase nurses' perceived ability to identify pertinent information vs. non-pertinent information. Acknowledgments I would like to thank my project chair, Nancy A. Allen, for the guidance, wisdom, and encouragement she provided throughout the development, implementation, and evaluation of this project. I would also like to thank George K. Sowles, James Bayon, and Sheryl Salmon for their STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT support and time spent reviewing and discussing how to best implement this project in the identified setting. 26 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 27 References Abraham, J., Kannampallil, T. G., & Patel, V. L. (2011). Bridging gaps in handoffs: A continuity of care based approach. Journal of Biomedical Informatics, 45, pp. 240-254. Chung, K., Davis, I., Moughrabi, S., & Gawlinski, A. (2011). 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STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 31 Figure 1 Pre-Intervention Survey Results 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 12% 6% 18% 18% 41%47% 47% 65% 41% 6% 29% 18% Strongly agree 18% 23% 23% 18% Agree 6% 18% Neutral 6% 12% 41% 41% 53% 6% 29% 18% 29% 12% 6% 18% 23% 6% 53% Disagree 12% 6% 18% 18% 23% 47% 65% 41% 41% 12% 12% 41% 12% 12% 29% 6% Strongly disagree STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 32 Figure 2 Post-Intervention Survey Results 100% 90% 80% 70% 60% 6% 6% 59%29% 50% 40% 23% 30% 20% 10% 0% 23% 29% 6% 6% 18% 18% 12% 59% 47% Strongly agree 29% 65… 18% 35% 59% 24% 6% 11% 41% Agree 35% 26% Neutral 12% 6% 18% 18% 12% 12% 45% 53% 18% Disagree 12% 35% 65% 41% 53% 35% 5% 35% 18% 12% Strongly disagree 18% STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT Figure 3 Pre-Intervention and Post-Intervention Survey Data (p<0.05) Question 1. Well-organized 2. Too much information 3. Consistent quality 4. Chart search for omitted patient info 5. Background information 6. Active hospital problems 7. Nursing interventions 8. Clinical course timeline 9. Summarize patient info in BH Kardex sticky 10. Risk assessment 11. Important info is omitted 12. Overall satisfaction PrePostIntervention Intervention Mean Mean 2.6 3.4 3.5 2.2 2.5 2.4 3.4 2.7 1.7 2.2 2.7 2.8 Asymp Sig P-value (2tailed) 1.9 3.5 2.7 1.6 1.9 1.9 2.8 2.5 1.5 1.8 2.9 2.1 Note: 1= strongly agree, 2= agree, 3= neutral, 4= disagree, 5= strongly disagree (p<0.05) 0.015 0.599 0.02 0.026 0.031 0.063 0.06 0.52 0.414 0.057 0.166 0.008 33 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT Figure 4 Needs' Assessment Survey Data: A Comparison of RNs vs. Psych Techs Question Asymp. Sig. (2tailed) Mean (RN) Mean (Psych tech) 2.09 2.05 0.926 2 2.47 0.178 I am provided with a satisfactory amount of information on each patient during shift report 2.45 1.95 0.268 The information I receive during shift report is accurate 2.18 1.89 0.553 Important information is left out of shift report 2.36 2.68 0.567 Information is provided in a clear and concise manner 1.82 2.21 0.283 Shift report includes more information than necessary 2.82 2.58 0.377 Shift report informs me of the plan of care/treatment plan for each patient 3.64 3.63 0.835 The information provided during shift report is subjective The information I receive during report aids my clinical decision-making on the upcoming shift 2.45 2.32 0.755 2.09 1.89 0.698 I view listening to shift report as an important part of my shift 1.09 1.95 0.005 The overall quality of shift report is consistent regardless of the reporter 3.64 3.42 0.739 The information I receive during shift report helps me to anticipate the needs of my patients for the upcoming shift 1.91 2.21 0.375 The information provided in shift report is relevant to my upcoming shift 1.73 2.16 0.128 Shift report includes explicit suggestions and/or recommendations for managing anticipated events that may occur 2.18 2.26 0.84 The main content I receive during shift report is variable depending on the reporter 1.64 1.63 0.613 2.09 1.89 0.609 2.18 2.26 0.982 The quality of shift report greatly impacts staff and patient safety 1.45 1.74 0.391 Overall, I am satisfied with current shift report practices on this unit 2.36 2.68 0.603 Shift report is well-organized The duration of shift report is <30 minutes If information is omitted or misunderstood during shift report, there may be serious clinical consequences Shift report repeats information that is available on a printout 34 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 35 Figure 5 Needs' Assessment Survey Data: A Comparison of Core Staff vs. Float Pool Staff Question Mean (Core) Mean (Float Pool) Asymp. Sig. (2-tailed) Shift report is well-organized 2.04 2.14 .342 The duration of shift report is <30 minutes 2.17 2.71 .240 I am provided with a satisfactory amount of information on each patient during shift report 2.13 2.14 0.713 The information I receive during shift report is accurate 2.04 1.86 0.724 Important information is left out of shift report 2.43 3.00 0.481 Information is provided in a clear and concise manner 2.22 1.57 0.376 Shift report includes more information than necessary Shift report informs me of the plan of care/treatment plan for each patient 2.65 2.71 0.802 3.74 3.29 0.562 The information provided during shift report is subjective 2.39 2.29 0.799 The information I receive during report aids my clinical decision-making on the upcoming shift 1.91 2.14 0.149 I view listening to shift report as an important part of my shift 1.65 1.57 0.557 The overall quality of shift report is consistent regardless of the reporter 3.65 3.00 0.543 The information I receive during shift report helps me to anticipate the needs of my patients for the upcoming shift 2.17 1.86 0.936 The information provided in shift report is relevant to my upcoming shift 2.04 1.86 0.772 2.26 2.14 0.878 1.61 1.71 0.528 1.83 2.43 0.095 2.09 2.71 0.412 1.65 1.57 0.955 2.70 2.14 0.643 Shift report includes explicit suggestions and/or recommendations for managing anticipated events that may occur The main content I receive during shift report is variable depending on the reporter If information is omitted or misunderstood during shift report, there may be serious clinical consequences Shift report repeats information that is available on a print-out The quality of shift report greatly impacts staff and patient safety Overall, I am satisfied with current shift report practices on this unit STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 36 Table 1 Needs assessment survey themes and subthemes Themes Barriers to quality shift report • • • • • • • • • Critical content • • • • • • • • • • • • Facilitators to quality shift report • • • Subthemes Interruptions; side-talking Subjectivity, conjecture Inconsistent content Reading information that is easily accessible in the chart and omitting info that isn't on the Kardex Too much retrospective info Information being geared towards RNs only Vague information Low volume of recorded report Reading off the sticky note Plan of care, nursing interventions Upcoming tasks Contingency plans, how to handle certain behaviors Toxic dynamics with other patients or family Current info on pain, meds, MSE Historical data that may impact care How to mitigate risks Progress towards treatment goals Abnormal VS or labs Current safety status (risk) Report by exception Info that doesn't have significant bearing on the patient's current status Provide RNs with a checklist for pertinent content to include in report for this unit to improve consistency and reduce omissions Prospective info to guide interventions and decision-making on shift Chronological organization of information STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT Table 2 Needs' Assessment Survey: Demographics N % 1 2 5 4 5 5.9% 11.8% 29.4% 23.5% 29.4% Gender Male Female 7 10 41.2% 58.8% Position Registered Nurse Psychiatric Technician 11 6 64.7% 35.3% Years at facility 0-2 years 2-5 years 5-10 years 10+ years 6 2 4 5 35.3% 11.8% 23.5% 29.4% 17 100% Characteristic Age 18-25 years 26-30 years 31-40 years 41-50 years 50+ years Total M SD 37 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT Table 3 Pre/Post-Intervention Survey: Demographics N % 1 2 5 4 5 5.9% 11.8% 29.4% 23.5% 29.4% Gender Male Female 7 10 41.2% 58.8% Position Registered Nurse Psychiatric Technician 11 6 64.7% 35.3% Years at facility 0-2 years 2-5 years 5-10 years 10+ years 6 2 4 5 35.3% 11.8% 23.5% 29.4% 17 100% Characteristic Age 18-25 years 26-30 years 31-40 years 41-50 years 50+ years Total M SD 38 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT Appendix A Nursing Shift Report Scale- Needs' Assessment Survey 39 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 40 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 41 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT Appendix B Shift Report Evaluation Scale- Pre/Post-Intervention Survey 42 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 43 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT Appendix C Intervention: Standardized Format for Kardex Sticky Note 44 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT Appendix D Permission to Use Handover Evaluation Scale 45 STANDARDIZING THE CONTENT OF NURSING SHIFT-TO-SHIFT REPORT 46