Nurses perceptions of patient handoffs and predictors of patient handoff perceptions in tertiary care hospitals in Kelantan, Malaysia: a cross-sectional study

Introduction

Patient handoff is a critical process in healthcare that involves the transfer of patient care from one healthcare provider to another and occurs at various points along the healthcare delivery system.1 In Malaysia, nursing handoffs, also referred to as pass-overs, play a vital role in ensuring continuity of care. These handoffs in general wards typically occur at least three times a day for certain patients, although the frequency may vary depending on the setting and patients’ needs. During the handoffs, nurses transferring patients provide receiving nurses with updates on patient conditions and treatments. Detailed handoffs during patient transfers ensure smooth transitions with critical information exchange, enhancing interdisciplinary collaboration for coordinated care. Rapid communication in critical situations ensures timely interventions, while meticulous documentation in patient records maintains the accessibility of vital information for all team members.

Nurses frequently handle handoffs, which are crucial moments for passing patient information between healthcare providers. Poorly managed handoffs can lead to patient harm due to misunderstandings and communication breakdowns.2 Miscommunications are a major cause of serious adverse outcomes. Nurses have a key role in ensuring continuity and safety in patient care by sharing accurate information during transitions and helping new nurses understand patient needs. However, effective communication during handoffs can be challenging due to various barriers. Nurses evaluate the effectiveness of handoff communication and hold each other accountable.3

Patient safety is a major concern in healthcare due to the high number of deaths caused by medical errors. Globally, unexpected complications from poor medical care are among the top 10 leading causes of death and illness.4 Communication breakdowns are a primary factor contributing to sentinel events and the most severe adverse outcomes, with 40% of such failures attributed to inadequate handoffs. This issue also contributes significantly to malpractice claims, placing a substantial financial strain on the healthcare system.5 Efforts to improve patient safety are vital in complex healthcare systems. It is not just about following rules and preventing errors; healthcare professionals must also build a resilient system that consistently delivers effective care. This requires a shift in mindset, enabling clinicians to adapt and improve their ability to provide quality care.

In Malaysia, patient safety is a top priority overseen by the Malaysian Patient Safety Council, which aims to ensure safe healthcare services. The Malaysia Patient Safety Goals (MPSGs) set standards for patient safety in the country. However, challenges such as medication errors, clinical management mistakes and patient falls still occur in Malaysian healthcare facilities.6 To improve patient safety and care, it is vital to address these issues and uphold high standards. Effective sharing of information among healthcare teams is crucial for safe and quality patient care. Mistakes during patient handoffs can lead to harm, reduced quality of care, longer hospital stays, increased costs and even fatalities.7 Continuous and effective interventions to enhance patient safety are essential to tackle challenges in mortality and morbidity.

Thus, the objectives of this study are to determine the mean perception score of patient handoffs among nurses in tertiary care hospitals in Kelantan, Malaysia, and to identify predictors of patient handoff perception. Significant predictors, including sociodemographic and working characteristics, are hypothesised to influence nurses’ perception of patient handoffs in these hospitals. Considering these predictors can contribute to a comprehensive understanding of handoff perceptions and guide future research. The findings will serve as a point of reference for stakeholders and researchers in devising intervention strategies and designing future studies.

Methods

Results

Discussion

The mean age of the participants was 41.06±6.26 years, similar to a study conducted in Switzerland.11 However, it is higher compared with other studies conducted in different countries, indicating a younger nurse workforce in those regions.12–16 Most participants were female, consistent with previous studies in Malaysia and globally showing a predominantly female nursing profession.17–19 Many nurses were married, suggesting that nursing is viewed as a stable profession suitable for family life.

Nurses are essential for providing excellent patient care. To address the growing need for skilled nurses, various nursing programmes have been created. Nurses often pursue further education, such as postbasic and degree-level studies. However, in our study, the percentage of nurses with a degree was lower compared with Hong Kong, indicating potential disparities in educational opportunities and cultural influences.20 Investing in nursing education is vital for maintaining high-quality care. Higher education can lead to more effective handoff communication among nurses, patients and their families, thereby improving the ability to communicate skilfully and deliver high-quality care.21 22

The participants had a mean working experience of 16.80±6.12 years, which was greater than in previous studies.13 23–25 More experience can help nurses handle complex cases better, communicate effectively during handoffs and identify safety risks. In our study, handoff duration was 24.39±10.68 min, longer than in a study in Nepal.13 Longer handoff durations are vital for ensuring comprehensive communication of critical information, especially for patients with complex conditions, thereby preventing adverse events and maintaining continuity of care. Precise and effective communication during handoffs is essential for early detection and timely response to patient needs, ensuring that all relevant details are thoroughly discussed.26 27 The detailed nature of these handoffs is influenced by the complexity of the patient’s conditions and the need to customise the information based on the receiving nurse’s preferences and previous experiences.28

In our study, bedside handoffs were the most common practice, which agrees with previous research showing the benefits of doing handoffs near the patient.3 29 30 Bedside handoffs involve patients, allow visual assessments and help plan care ahead. Patients like bedside handoffs because they feel involved, trusted and empowered.31–33 When patients are included, healthcare providers can significantly improve outcomes, reduce errors and increase patient satisfaction.34 However, concerns among nurses include time constraints, confidentiality and potential reduction in collaboration.35–38 Additionally, lack of time may be associated with staffing ratios and the need for nurses to perform non-nursing tasks.39–41

The importance of having handoff guidelines is supported by a study in Korea, which found that standardised guidelines can improve the organisation and structure of handoff communication, leading to better patient safety.42 Without these guidelines, there can be inconsistent and incomplete transfer of patient care responsibility, leading to errors and delays in care. On the other hand, implementing standardised guidelines provides a clear framework for handoff communication, ensuring that all essential information is effectively and efficiently transmitted.

In tertiary care hospitals in Kelantan, Malaysia, the average perception score for patient handoffs was 3.53, showing a positive perception. However, this was slightly lower than a recent 2022 study where the score was 3.9.43 Nursing staff showed the most positive perception about management goals, suggesting that they understood the goals and objectives of patient handoffs well. This positive outlook was likely influenced by effective communication and collaboration among healthcare providers involved in handoffs.

The nurses rated the patient handoff process as excellent, a finding seen in international research where healthcare staff consistently report high-quality handoffs.44–46 Nurses’ assessment of handoffs is crucial for patient care quality. Effective communication during handoffs ensures smooth care transitions and reduces the risk of errors. So, a positive evaluation of handoffs means patients get top-notch care.

Participants believed that handoffs between departments/wards were done effectively, leading to a significant improvement in handoff quality.47 48 However, some studies have shown the need for better communication and structure in handoffs to ensure patient safety and continuous care.49 Hospitals can improve handoff quality and reduce adverse events by using standardised handoff tools and protocols.

Nurses knew their roles during handoffs, reducing errors and improving effectiveness. Continuous education ensures healthcare professionals understand their responsibilities during handoffs. Nurses can enhance patient safety by using risk-aware handoff strategies, being active participants and promoting shared decision-making.50 New staff members regularly receive formal training for handoffs, crucial for communication and teamwork skills. Simulation-based training has proven effective in improving handoff performance and boosting nurses’ confidence and communication abilities.51 52

Participants viewed mutual communication, information transfer and the handoff system positively, which are vital for efficient patient care transfer. Effective communication and information conveyance support successful handoffs. Nurses demonstrated strong abilities in active dialogue, scenario discussions and seeking education, aligning with studies emphasising respectful partnership and communication for seamless care. Fostering candid communication and respect improves collaboration and patient care.53 54 Strategies such as standardising communication, providing structured tools and emphasising information accuracy have been found to improve information transfer, workflow, and productivity.55

Participants expressed concerns during handoffs, which improves patient safety and care quality. Involving all team members and encouraging open discussions reduce errors.56 Nurses should promote honesty and clarity in discussions, especially during handoffs, to prevent errors and miscommunication.57 Barriers to voicing concerns include concerns about effectiveness and safety, power differences, and lack of familiarity.58 59

The study found that there is a borderline perception score for insufficient handoff information, highlighting the importance of having enough relevant information. Nurses prioritise the quality of information, and not having enough of it can lead to harmful outcomes like treatment delays and inaccurate diagnoses for both patients and nurses.60 61 Training and education are crucial for handoff personnel to prevent negative incidents in patient care due to inexperienced or less capable staff. Consistent education and training improve nurses’ competence and confidence, preventing communication breakdowns and medical errors. Ongoing training ensures skilled and confident handoff personnel.62 63

Nurses identified unclear responsibility for patients after handoffs as a significant concern. This confusion can lead to care delays and adverse events, especially during unit transitions. Improved communication and documentation were suggested to clarify roles. Clear role delineation is crucial for patient care and team success.64 Comprehensive role descriptions enhance job satisfaction by improving workplace support, and linking role clarity with social support.65

Nurses indicated that the patient handoff process in their hospital was satisfactory and did not need improvement. However, enhancing this process through standardised procedures, guidelines and electronic health records (EHRs) is recommended to ensure continuity of care and improve accuracy and completeness by providing easy access to patient information. Challenges in implementing EHRs include financial constraints, technological issues, lack of standardisation, behavioural obstacles and organisational limitations.66 Repetitive documentation, manual data entry and separate tracking systems can lead to confusion and inefficiencies.67 Nurses disagreed about being too busy to respond quickly to newly received patients, emphasising that quick responses during handoffs are crucial for continuity of care. For example, in critical care units, limited time for handoffs can impact information quality, affecting the receiving nurse’s ability to provide timely care. Detailed information about high-risk patients is more likely provided during handoffs.68 Prompt nurse responses are linked to fewer adverse events, shorter hospital stays and lower readmission rates, highlighting the need for timely responses.69

Timely follow-ups and support for patient care after a handoff are crucial for positive outcomes and continuity of care. Such follow-ups improve outcomes and reduce readmissions, while accurate medication reconciliation and efficient handoff services enhance satisfaction, treatment outcomes and reduce costs.70 Inadequate follow-up can lead to negative health outcomes and higher expenses. Communication breakdowns during transitions can disrupt care, jeopardise safety and waste resources, increasing costs. Therefore, standardising follow-up procedures and ensuring accountability is recommended.71 72

The study’s MLR analysis revealed predictors of how nurses in tertiary care hospitals in Kelantan, Malaysia perceive patient handoffs. Satisfaction with the handoff process in the current ward and receiving formal training on handoffs had a positive impact on perception. However, the paediatric department had a negative effect. Most participants were satisfied with handoffs in their wards, indicating effective execution and positive outcomes. This supports other studies emphasising handoff satisfaction for patient safety and staff contentment.73–75 Providing in-service training to healthcare professionals involved in handoffs is crucial and was observed in many participants. Insufficient training can cause communication errors and harm patients, stressing the importance of ongoing education.76 77 This shows a dedicated effort to equip healthcare professionals with the necessary knowledge and skills for effective handoffs, vital for patient care.

In our study, we discovered that nurses in the paediatric department tended to view handoff practices less favourably compared with those in other departments. Based on our research and available literature, there is limited information comparing nurses’ perceptions of handoff practices across different clinical areas. This makes it challenging to directly compare our findings with other studies. However, our results are valuable for programme planners, highlighting areas in clinical practice that may need extra attention to enhance quality and ensure patient safety.

Based on the study findings, we propose a future interventional study to evaluate and improve the handoff process by implementing a digital or electronic handoff system. This system aims to enhance communication, reduce errors, ensure accessibility and streamline efficiency during patient handoffs in healthcare settings. In addition, training and support for nurses are necessary, as appropriate training and education can equip them with the required skills and knowledge.