Handoff Communication Practices Among Emergency and Critical Care Nurses During Patient Transfers

Introduction

Handoff communication during the transfer of a patient from the emergency department to an inpatient unit is a widely recognized high-risk point for information loss, with prior research consistently linking incomplete or inaccurate handoff communication to downstream adverse events and near misses (Riesenberg et al., 2010; Friesen et al., 2008). Structured handoff tools, including SBAR (Situation, Background, Assessment, Recommendation) and the more recently developed I-PASS framework, have been developed and, in several large-scale implementation studies, shown to reduce medical errors and improve information transfer when applied with fidelity (Starmer et al., 2014; Cornell et al., 2014).

Despite this evidence, prior research has also documented a persistent gap between a structured handoff tool’s formal availability and its actual, consistent application at the bedside, with observational audit studies frequently finding that certain tool elements are reliably included while others are inconsistently or rarely addressed (Jeffcott et al., 2009; Abraham et al., 2014). Observational and audit-based research of this kind is well suited to quantifying precisely which elements are omitted and how frequently, but is comparatively limited in its ability to explain why specific elements are more vulnerable to omission than others, a question better suited to nurses’ own qualitative accounts of the barriers they experience during an actual handoff (Redfern et al., 2009; Streeter & Harrington, 2017).

A convergent parallel mixed-methods design, in which quantitative and qualitative data are collected and analyzed independently before being deliberately merged for joint interpretation, is well suited to this specific combination of research aims, allowing a structured, quantitative account of what is and is not communicated to be directly integrated with a qualitative account of why, achieved through a formal, joint comparison of the two independently derived sets of findings (Creswell & Plano Clark, 2018; Fetters et al., 2013). The purpose of this study was to examine the completeness and accuracy of emergency-to-inpatient handoff communication and to explore emergency and receiving-unit nurses’ perspectives on the barriers underlying incomplete handoff communication.

Methods

Design. This study used a convergent parallel mixed-methods design, in which quantitative and qualitative data were collected concurrently and analyzed independently, with integration occurring only after each strand’s independent analysis was complete, consistent with Creswell and Plano Clark’s (2018) description of this design’s purpose: using two distinct forms of data to develop a more complete understanding than either method could provide alone. Table 1 summarizes the two strands.

Quantitative strand. Trained, non-participating observers directly observed 180 consecutive, consenting emergency-to-inpatient handoffs across three hospitals, scoring each handoff against a structured completeness checklist derived from core I-PASS and SBAR elements: illness severity/acuity, patient summary, action items/pending tasks, situational awareness/contingency planning, receiver synthesis or read-back, allergy status, code status, and critical value reporting. Following observation, reported critical values (vital signs, key laboratory results) were verified against the medical record to assess reporting accuracy. Number of interruptions and total handoff duration were recorded for each observed handoff, and compared between emergency-to-intensive-care-unit and emergency-to-ward transfers.

Qualitative strand. Four semi-structured focus groups, two composed of emergency department nurses and two composed of receiving-unit (intensive care unit and general ward) nurses, were conducted with a total of 24 nurses, exploring perceived barriers to complete handoff communication, experiences of information loss during transfer, and informal workarounds nurses had developed. Transcripts were analyzed using reflexive thematic analysis following Braun and Clarke’s approach, proceeding through familiarization, coding, theme development, and review.

Integration. Following independent analysis of each strand, quantitative completeness findings and qualitative themes were formally compared through a joint, side-by-side interpretive process, examining specifically where the lowest-completeness quantitative elements aligned with, were explained by, or diverged from the qualitative themes, consistent with recommended joint display and integration practice for convergent mixed-methods designs (Fetters et al., 2013).

Results

Quantitative findings. Handoff element completeness varied substantially across the 180 observed handoffs, ranked from highest to lowest in Figure 1. Straightforward, checklist-style elements showed high completeness, while elements requiring active synthesis or receiver engagement showed markedly lower completeness.

Interruptions and handoff duration differed significantly by destination unit type. Emergency-to-intensive-care-unit handoffs involved a mean of 3.8 interruptions and lasted a mean of 6.4 minutes, compared with a mean of 2.1 interruptions and 4.1 minutes for emergency-to-ward handoffs (both p < .001).

Qualitative findings. Reflexive thematic analysis of the four focus groups resulted in four themes. Time pressure undermines structure captured participants’ description of abandoning a structured tool’s more time-intensive elements, particularly synthesis and contingency planning, during periods of high department volume. The verbal report and the chart tell different stories described participants’ recurring experience of discovering, only after a patient arrived on the unit, that a verbally reported value or detail did not match the documented record. No shared definition of “critical” information captured disagreement, both within and between emergency and receiving-unit nurses, about which specific details genuinely warranted mention during a necessarily time-limited handoff. The tool exists, the habit doesn’t described participants’ acknowledgment that a structured handoff tool was formally available and trained, but had not become an automatic, habitual practice for many nurses, particularly its more effortful synthesis-oriented components.

Integration. Joint comparison of the two strands, illustrated in Figure 2, showed close alignment between the lowest-completeness quantitative elements and specific qualitative themes.

Discussion

This convergent parallel mixed-methods study found that emergency-to-inpatient handoff communication showed consistently high completeness for straightforward, checklist-style elements but substantially lower completeness for elements requiring active synthesis or receiver engagement, and that this specific pattern was closely explained by nurses’ own qualitative accounts of time pressure and habitual, effortful-element abandonment rather than a lack of formal training or tool availability. This finding is consistent with prior observational audit research documenting uneven element-level completeness within structured handoff tools (Jeffcott et al., 2009; Abraham et al., 2014), while extending this literature through the direct, joint integration of quantitative completeness data with nurses’ own explanatory account, made possible by this study’s convergent parallel design (Fetters et al., 2013).

The convergence map in Figure 2 makes visible a specific and actionable distinction: the two lowest-completeness elements, situational awareness/contingency planning and receiver synthesis or read-back, both converged with two related qualitative themes (time pressure and habitual tool abandonment), suggesting these two elements may share a common underlying barrier, namely that they require active, effortful cognitive synthesis rather than straightforward factual reporting, and are therefore the first elements sacrificed under time pressure. This distinction has direct implications for improvement strategy: interventions addressing time pressure and reinforcing synthesis as an automatic habit, rather than generic handoff retraining addressing all elements uniformly, may be better targeted to the specific elements shown in this study to be most vulnerable.

The critical-value discrepancy finding, with nearly three in ten applicable handoffs showing a mismatch between the verbally reported value and the chart-documented value, converging specifically with participants’ qualitative description of verbal report and chart divergence, represents a distinct and separately actionable finding from the synthesis-element gap. This pattern, and its convergence with a qualitatively distinct explanatory theme, suggests that improving critical-value accuracy may require a different intervention, such as structured, chart-anchored value verification built directly into the handoff tool, rather than the time-pressure and habit-focused interventions more directly relevant to the synthesis-element gap.

The significantly greater interruption count and duration observed for emergency-to-intensive-care-unit transfers relative to emergency-to-ward transfers is consistent with the generally higher acuity and more complex clinical picture typical of intensive care unit admissions, and offers a plausible additional explanation, alongside the qualitative time-pressure theme, for why synthesis-oriented elements may be particularly vulnerable during exactly the transfers where their omission carries the greatest clinical consequence.

Several limitations should be considered. Direct observation of handoff communication, despite efforts to minimize observer influence, carries some risk of a Hawthorne effect, in which nurses may have communicated somewhat more completely than their unobserved baseline practice, suggesting the true completeness gaps documented in this study may, if anything, be conservative underestimates. This study was conducted within three hospitals in a single general region, and generalizability to health systems with different handoff tool implementation, staffing models, or unit acuity distribution should be considered carefully. The convergent parallel design’s integration step, while following recommended joint comparison practice, remains an interpretive process conducted by this study’s specific research team.

Future research should evaluate whether an intervention specifically targeting the two identified vulnerable elements, situational awareness/contingency planning and receiver synthesis, through structured time protection and deliberate habit-formation strategies rather than generic retraining, measurably improves completeness of these specific elements without displacing attention from already high-completeness elements. Extending this convergent mixed-methods approach to other high-risk transition points, such as intensive care unit-to-ward transfer or shift-to-shift handoff within a single unit, would help clarify whether the specific pattern identified here, synthesis-oriented elements as the most time-pressure-vulnerable, generalizes across different types of nursing handoff. Taken together, these findings demonstrate the value of directly integrating quantitative completeness data with nurses’ own qualitative explanation, identifying specific, differentiated improvement targets that neither data source would have revealed as clearly on its own.

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