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Innovative Approach to Reconstruct Bedside Handoff: Using Simple Rules of Complexity Science to Promote Partnership With Patients

Anthony, Mary, K., PhD, RN, CS; Kloos, Janet, PhD, RN, CCNS, CCRN; Beam, Patricia, DNP, RN-BC; Vidal, Kathleen, MSN, RN, NEA-BC

doi: 10.1097/NCQ.0000000000000280

When nurses integrate patient expertise, nurse-to-nurse handoff becomes patient-centered (nurse and patient), and the weak link between quality and safety is mitigated. The existing paradigm for handoff is an ineffective measure to minimize errors. This article describes a reimagined bedside handoff—transitioning handoff from its prescriptive nurse-centered interaction to a patient-centered partnership using the principles of complex adaptive systems, simple rules, and partnerships that address the uniqueness of each patient and nurse interaction.

University Hospitals Cleveland Medical Center, Cleveland, Ohio (Drs Anthony and Kloos); Kent State University College of Nursing, Kent, Ohio (Dr Anthony); UH/Rainbow Babies & Children's Hospital, Cleveland, Ohio (Dr Beam); and University Hospitals Home Care Services, Cleveland, Ohio (Ms Vidal).

Correspondence: Mary K. Anthony, PhD, RN, CS, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106 (;

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

The authors declare no conflicts of interest.

Accepted for publication: June 7, 2017

Published ahead of print: August 1, 2017

TO IMPROVE the delivery of health care, the landmark document, Crossing the Quality Chasm: A New Health System for the 21st Century, outlined 10 principles that redirected health care delivery from being a provider-driven paradigm to one that is patient-centered.1 Since then, the conceptualization and practice of patient centeredness have evolved, as mounting evidence supporting patients' role in information sharing and deliberation has demonstrated a positive impact on outcomes.2,3 Patient centeredness has been reimagined to describe patients as partners and members of a high-functioning health care team.2 Despite these initiatives, 1 in 10 patients continue to be harmed by the care they receive.4

Provider and patient partnerships are most often described in terms of patient values and preferences in decision making related to disease management and treatment. However, patient partnership across all aspects of care is a recently recognized strategy to improve quality and make care safer.5 One care activity in which partnership can impact outcomes is the shift-to-shift bedside handoff, a high-stakes activity that may be prone to cognitive bias or flaws in judgment resulting in communication failures, which is one of the leading causes of sentinel events in hospitals.6,7 Information about the importance of handoff and its corresponding evidence is voluminous, but remains largely limited to descriptions of nurse-driven interventions to improve accuracy of information transfer, decision making, continuity, and safety during handoff.8,9 Many models of new handoff practices described as being patient-centered actually describe a more limited patient “sensitive” structured approach that suggests a 1-way information flow, with patients being “invited” to participate at the conclusion of the nurse-to-nurse handoff.10 Despite good intentions to revamp handoff, the majority of existing strategies fail to actively engage the patient's voice, limiting effective communication, and thus continue to represent a weak link in quality and safety.

Envisioning the bedside handoff as a unique partnership offers significant possibilities for improved quality and safety. Therefore, the purpose of this article is to offer a conceptual redirection that provides a platform for achieving a true patient partnership. Using the dynamic and adaptive concepts and methods from complexity science, we suggest the use of simple rules as a pathway that transitions the patient from being an audience during handoff to an engaged participant. The bedside handoff, when restructured as a partnership, emphasizes what matters to nurses as a benchmark for good practice and what matters most to patients, collectively serving to improve error recognition, add lost information, and facilitate shared decision making.

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Although it is a widely recognized approach in education and across a variety of business-related sectors,2,11,12 the formation of an active and engaged partnership between a health care provider and a patient/family is a relatively new approach to achieving improved outcomes in health care delivery. Partnerships, in general, are characterized as having purposive, strategic, engaged, and reciprocal relationships in which parties share mutual goals and benefits and are jointly accountable for outcomes.11–13

In health care, partnerships involve a process that embodies empowering the patient, as an expert, to be an active participant in understanding, planning, and negotiating care for mutual benefit.2,13,14 Attributes of partnerships include shared decision making, relationships, professional competence, shared knowledge, autonomy, communication, participation, and shared power.15 Consequences of partnerships include developing shared mental models that can improve patient outcomes,15,16 such as treatment adherence and decreased health care costs.3 Although nurses philosophically understand the need for patients as partners, paradoxically, they wrestle with the practicalities of operationalizing that partnership.

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Patients as partners

When patients become partners, they must be viewed and respected as integral members of the health care provider team.2 Operationalizing that partnership requires that the roles and responsibilities are built around the expertise of both the provider and the patient. Providers contribute clinical knowledge as well as skill and ability in understanding and managing complex conditions. However, patients bring their unique perspectives, values, beliefs, and experiences in managing their conditions.13 Patients are experts on their histories, treatments, and health care problems and are a vanguard for maintaining safe and error-free care. Integration of these 2 unique but equally important types of expertise requires the nurse to be cognizant of the patient's expertise while establishing a successful patient-centered partnership.

Health care team members are advised to provide guidelines to patients and families as to “how to define outcomes that matter most to them in order to align care with their individual capabilities, preferences, and values.”2(p10) Developing a shared understanding of what matters most can then be translated into agreed-upon goals of care whereby progress can be evaluated and refined. Ultimately, patients are instrumental to developing, refining, and updating goals. Bedside handoff is one interaction in which shared goals provide a roadmap for guiding the ongoing work of the partnership.

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Bedside handoff is a critical transition time for achieving continuity of care and safety outcomes.17–19 It involves the transfer of responsibility and information from an off-going nurse to an in-coming nurse and is intended to include accurate and pertinent information in a seamless manner.17,20 Patients and families are largely passive participants in the process because handoffs are tailored toward the nurse8,20,21 and thus inadvertently introduce cognitive bias or perceptual distortions, leading to flawed judgments and decisions.6 As a result of this passivity, there is a lost opportunity to create shared mental models about the condition of the patient and to create a collective understanding that can prevent cognitive bias, communication failures, and patient harm.22

A review of current research on bedside handoff describes a nurse-driven and prescriptive process of an in-coming and off-going nurse communicating information in the presence of a patient.8,19,23,24 At the conclusion of this nurse-driven handoff, patient participation is allowed.

Standardized approaches to handoff offer limited benefits to quality and safety. In 1 study, patients who experienced bedside handoff in a consistent manner reported feeling protected from errors and that nurses planned for and informed patients of their care.18 Use of acronyms, such as SBAR (Situation, Background, Assessment, Recommendations) or ISHAPED (Introduce, Story, History, Assess, Plan Error Prevention, Dialogue), or similar structured methods to relate key information about the patient and plan for the day has been suggested as the standard for bedside handoff.17,22,25

In a 2016 systematic review, 34% of the articles included used mnemonics for bedside handoffs.26 However, evidence about the benefit of mnemonics is lacking.10,24,26 Although prescriptive approaches during bedside handoff offer efficiency and limited benefits to safety, advocating the use of a nonflexible format may introduce cognitive bias resulting from nurses' rapid thinking and use of rules of thumb.6 Conversely, true partnerships offer opportunities for more deliberate thinking that limits the framing effects of cognitive bias and incorporates better decision making and actions that prevent harm.

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Nurses engage in a multitude of patient interactions in which partnerships can be initiated and strengthened. Integrating the principles of partnership by placing the patient at the center of handoff facilitates identification of the patient's priorities and creates an opportunity for collaboration in decision making.27 Thus, bedside handoff provides the structure and process for patients to amplify, clarify, and recall information that preserves the integrity of information necessary for safe outcomes.

Transitioning from a patient-sensitive to a patient-centered handoff requires recognition of its uniqueness and complexity.27,28 Every patient has an individual story, previous experiences that influence their logic and emotion. Each nurse brings the expertise of their years of practice, along with the knowledge, skill, and ability to communicate effectively. Therefore, each episode of handoff integrates a constellation of these individuals' characteristics at a certain time. If each patient-centered bedside handoff is unique, prescriptive approaches are counterintuitive. Including patient input at handoff becomes a checkpoint for accuracy, clarification, and avoidance of error. Thus, the principles of complexity and development of simple rules better address the uniqueness of each patient interaction.29

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A flexible process for patient-centered bedside handoff is guided by the theoretical framework of complexity theory. In complex living systems, interactions among the parts are dynamic and nonlinear as well as interconnected and reciprocal and thus can have unpredictable responses.29,30 Applying this concept to bedside handoff, the patient may contribute unexpected information to the overall plan of care. As this interdependent conversation unfolds, the plan of care moves to the realm of partnership. Hawe et al31 explains complexity as a system in which there is difficulty precisely defining important characteristics and how they relate to each other. Complex systems are adaptive in that whenever change occurs either internally or in the environment, a feedback response follows to either create balance or reinforce a change or action to improve adaptation.

People within complex systems have a natural capacity for self-organization in which interactions and interdependence among them impact the adaptation of the system, and small changes can lead to large effects.32 These features of complexity are important to handoff because nurses may have organized what information should be shared with the patient through a shared vision so deeply ingrained that it may be difficult to expand their view of placing the patient at the center of the handoff. Our premise is that making a small change, using a nonprescriptive approach, to improve the quality of the interaction and create a shared mental model to incorporate patient priorities can have a powerful effect on improving safety and quality.

When a complex activity such as bedside handoff is regimented and prescribed, the capacity to adapt to variations in patient needs or preferences is flawed and can result in poor decision making. In contrast, partnerships acknowledge patients' expertise about their health history and treatment preferences. Aligning nurses' expertise in health care with patients' expertise in their own health creates a dynamic and reciprocal partnership in decision making with roles and responsibilities that lead to mutually identified outcomes. Establishing and sustaining a partnership that is dynamic in nature requires an approach that is uniquely responsive to each situation. Thus, reimagining the structure for the bedside handoff from a standardized and regimented activity to one that relies on flexible guidelines allowing a patient-centered handoff to unfold is likely to achieve partnership between the nurse and the patient.29

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Simple rules

One approach to managing complexity is to develop simple rules, which are a small set of nonprescriptive guidelines tailored to a specific activity or decision.29 By design, simple rules provide limited guidance, require the user to focus on what matters most, are tailored to the situation, and allow the user to exercise discretion.29,33 Simple rules were first described by the Institute of Medicine1 in articulating 21st-century tenets to redesign health care from provider driven to patient driven. Since these rules were published, patient-centered approaches have moved from shared approaches to active partnerships.2 We are proposing to extend the conceptualization and use of simple rules as a framework for partnerships to achieve a patient-centered bedside handoff for 3 reasons: first, they provide flexibility while maintaining consistency; second, simple rules improve decision making when information is limited and time is short; and third, simple rules allow individuals to synchronize their activities.29

Sull and Eisenhardt29 classify simple rules as being either decision or process rules. In establishing decision rules, boundaries are set, alternatives are prioritized, and stopping points are determined. Process rules, on the other hand, guide people to execute tasks, coordinate action, and establish timing.29,33 Thus, developing a set of simple rules incorporating both decision and process rules represents an innovative approach for designing a successful patient-centered bedside handoff.

We illustrate the use and relevance of 4 of the simple rules for a patient-centered bedside handoff. These 3 decision rules and 1 process rule are operationalized to demonstrate a structure for transitioning to a flexible, patient-centered handoff. Boundary rules are guidelines that serve as a quick screen to establish the extent the patient would like to partner. Boundary rules establish the uniqueness of the handoff while addressing the depth of what could be pursued when time is short. Boundary rules acknowledge that patients are stewards of information about their health, lifestyle, and self-management and are the best source of information to guide future plans. Priority rules can be used to understand and rank issues of importance to the nurse and the patient, gain patient-specific information upon which decisions should be based, and determine what matters most to patients. Nurse and patient contribute their expertise to develop a shared mental model for shared decision making and mutual benefit. The use of priority rules during handoff establishes a guideline for what can be addressed throughout the shift. Stopping rules will guide when the time-limited handoff is mutually finished. Lastly, coordination, a simple process rule, guides the interaction among the patient and the nurse and sets the stage for accomplishing the prioritized treatment plan care activities. An example of a bedside handoff using partnership and simple rules is in the Supplemental Digital Content, Table, available at:

To summarize, a simple rule is operationalized by the context-dependent, dynamic, and evolving nature of each nurse and patient interaction34 that underpins the formation of shared mental models. Therefore, decision and process simple rules are a set of guidelines developed by bedside nurses and patients, which ensure that bedside handoff is patient-centered. Simple rules can be adapted to the population of patients, and align with the culture and/or values that characterize a partnership in patient and nurse communication. The overall simple rule or metasimple rule is embedded in the language of partnership.

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Nurses philosophically ascribe to holistic care, which is a necessary but not sufficient criterion for engaging in patient-centered partnership. There is still much to learn to advance nursing practice to include a true partnership in which nurses engage with patients and families to achieve mutually agreed-upon outcomes.1 Nurses engage in a multitude of patient interactions in which partnerships can be initiated and strengthened, which fundamentally requires nurses' vigilance in recognizing patient expertise. Bedside handoff is one interaction representing a critical transition for achieving continuity of care and safety outcomes.17,18,19 Transitioning bedside handoff from its current nurse-centered interaction to a patient-centered partnership necessitates a nonlinear approach to move from a prescriptive communication style to one that is guided by a more flexible approach.

Decades of published literature and guidelines on bedside handoff attest to its being a wicked problem,35 supporting novel methods in recognizing each handoff as unique and instrumental to achieve aims of quality and safety. We recognize that the conceptual redirection we have described represents a shift in practices used for bedside handoff. Although we offer a small example of the use of simple rules (Supplemental Digital Content, Table, available at:, we acknowledge the underlying principle that simple rules are context dependent with flexibility to use discretion. For example, a patient newly diagnosed with cancer may not be able to actively engage in a partnership. Likewise, a person with a long length of stay may not have the need or desire to participate in a history review. An assessment of the patient's health literacy and acuity are additional determinants of context.

Using complexity science and simple rules to address the wicked problem moves away from the comfort of consistency and predictability with nurse-driven interactions. From that perspective, even the phrase “bedside handoff” may need to be reconsidered. The benefits of rethinking bedside handoff outweigh the challenges associated with shifting from the more predictable but less effective process currently being used. Learning how to use simple rules in conducting a partnership-driven handoff requires a new skill set for both nurses and patients. Nurses are educated as providers5 and so the transition to becoming a partner will require redirection and redefinition of their communication skills. The language of partnership engages the patient through conversational questioning followed by quality listening. In developing patient and provider partnerships, patients feel listened to by their providers, feel more cared for, and are able to participate to the extent they desire.2 Similarly, as patients and their families want to be recognized as stewards of their information, this also suggests a new learning experience for the patient. Empowering patients to participate in prioritization and decision making for their health and own self-management requires continuous opportunities to support an engaged partnership.

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Bedside handoff represents a complex, high-risk communication activity. This article suggests that the current handoff practices are ineffective and the use of simple rules represents a strategic redirection. As our dialogue and practice of using simple rules to achieve partnership matures, we will learn new takeaways to close the gap between provider-driven and patient-driven health care. Using boundary, priority, stopping, and coordination rules as a guide to a flexible and free-flowing conversational handoff recognizes the patient's expertise while providing the nurse a structure for their communication. This reimagined approach is likely to create a reaction among nursing professionals, consistent with change that underlies complexity science. However, as reaction turns to testing, creating this shared vision and path provides a roadmap for improved decision making as partners in creating a strong link for quality and safety outcomes.

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bedside handoff; complexity science; handoff; patient-centered care; patient partnership; simple rules

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