The limitations of handoff report

In bedside nursing, the nurse enters the story of the patient’s life at the point where the handoff report ends.

“Pt is an 8 mo old female, history of hypoxic ischemic encephalopathy (HIE), baseline 2L oxygen at home. Admitted to the unit for respiratory distress.”

Handoff report then goes through a systemic description of the patient’s current state: neurological, cardiovascular, respiratory, GI/GU, skin, and finally, psychosocial. The report is thorough but brief, never truly complete.

The oncoming nurse takes report and seeks to develop an accurate picture of her patient’s physiological state in order to anticipate emergencies and prioritize nursing interventions. But as any experienced nurse knows, no report can replace thorough and ongoing assessments—patients can change, and even the most expert nurses who have previously cared for this patient can miss details.

This holds true both in terms of a physiological assessment and a psychosocial assessment. What the nurse receives during handoff in terms of the patient and family’s psychosocial status is typically brief. “The patient’s parents are involved. Dad is a little more anxious and doesn’t stay at the bedside for long. Mom has a lot of questions, and she likes to help a lot with the hands-on care.”

Assumptions rush in to fill empty spaces

At some point in receiving report, likely on a subconscious level, the nurse is also filling in some of that narrative with her own thoughts or assumptions. I found myself doing this very thing with the parents of this infant with HIE. I skipped over what might have caused the baby’s condition, and immediately thought of the mom as the one who would devotedly care for her child—while in my mind, the dad was someone with one foot halfway out the door, given the demands of a special needs child.

I entered the room and briefly introduced myself to the parents. Though both were tired, they were cordial with me and interactive with their daughter. I assessed the baby, administered morning medications, and then turned to the parents to see if they needed anything or had questions before I left the room. I found myself addressing the mother more than the father. Somewhere deep inside, my assumptions and the ways I’d filled in the narrative were subtly working their way out in my level of engagement with each parent.

Assumptions vs. humility

Later in the day, the mom went home to gather some things. When I again entered the room to assess the baby, the father was there, quietly stroking his daughter’s head. He looked to be deep in thought. I cautiously asked, “Did your wife have birth trauma when your baby girl was born?”

He looked up from his place of reflection and began to tell me of how they were so excited to start a family. The pregnancy was fairly textbook. But a few hours into labor, her placenta tore, and the placental abruption caused the baby to be without oxygen for 11 minutes until the emergency C-section got their baby girl out. They were profoundly traumatized.

I was humbled to realize I had filled in their narrative in a way that was unjustified, and that this had subtly but surely affected the way I engaged and cared for the father. In hearing their story from the father, I realized these were parents who were still grieving the life and family they had envisioned, and who were still getting to know their daughter with special medical needs in ways that babysitting their friends’ healthy kids never could have prepared them for.

My understanding changed, and my heart followed suit. I found myself explaining things more thoroughly to the father and coming along beside him with a greater spirit of empathy and support.

I learned that day about the importance of being aware of the ways I fill in a patient and family’s narrative, perhaps with pieces of other similar narratives I have heard, or simply with my own unsupported assumptions and judgments.

The importance of listening

I also learned about the importance of asking humble questions when I realize I need the patient and the family to be the ones telling me their own story before I have painted it in my mind. “Tell me more about what happened. Tell me more about how this has affected you. Tell me more about how we as the nursing staff can help you.”

It is the voice of the patient and families themselves that can help the nurse better understand and respond to their story, often better than a thorough handoff report from the most experienced nurse. If met by enough curiosity, humility, and openness with skillful and thoughtful questions from the nurse, this voice can help guide the nurse’s care in significantly more meaningful ways.