A tool for assessing the quality of

nursing handovers: a validation study

Paolo Ferrara, Stefano Terzoni, Salvatore Davì, Alberto Bisesti, Anne Destrebecq

modern healthcare settings (Cohen and Hilligoss, 2009; Bulfone

ABSTRACT et al, 2012). Accessing primary care, being taken under the
Aim: Handover, in particular between two shifts, is a crucial aspect of nursing charge of another doctor or nurse, being discharged home or
for patient safety, aimed at ensuring continuity of care. During this process, towards other facilities are just a few examples that demonstrate
several factors can affect quality of care and cause errors. This study aimed how crucial handovers are for maintaining continuity of care
to assess quality of handovers, by validating the Handoff CEX-Italian scale. and therefore patient safety. This point has been emphasised
Method: The scale was translated from English into Italian and the content by the World Health Organization (WHO) Collaborating
validity index was calculated and internal consistency assessed. The scale Centre for Patient Safety Solutions (2007). This principle has
was used in several units of the San Paolo Teaching Hospital in Milan, Italy. been confirmed by the Joint Commission (2016) and Joint
Results: A total of 48 reports were assessed (192 evaluations). The median Commission International (2017), who pointed out that
score was 6, interquartile range (IQR) [5;7] and was not influenced by specific communication problems are frequently among the causes of
(p=0.21) or overall working experience (p=0.13). The domains showing the sentinel events (any unanticipated event in a healthcare setting
lowest median values (median=6, IQR [4;8]) were context, communication, resulting in death or serious physical or psychological injury
and organisation. Night to morning handovers obtained the lowest scores. to a patient or patients, not related to the natural course of the
CVI-S was 0.96, Cronbach’s alpha was 0.79. Discussion: The Handoff CEX- patient’s illness).
Italian scale is valid and reliable and it can be used to assess the quality of Nursing handovers are crucial during the patient’s pathway,
nurse handovers. with implications for safety and clinical risk management.
However, the international literature reports a lack of adequate
Key words: Nursing handover ■ Continuity of care ■ Patient safety
communication skills (McCabe, 2004; Siyambalapitiya et al,
2007; Ellison, 2015; Manias et al, 2016) and a variety of problems

I
at handovers, such as incomplete or inaccurate information
n healthcare settings, handover is commonly referred to as available, few chances to ask questions, repeated interruptions
the practice of exchanging clinical information regarding (Riesenberg et al, 2009;Welsh et al, 2010; Calleja et al, 2011), and
patients, between two or more professionals, during a insufficient time (Meissner et al, 2007; O’Connell et al, 2008).
change of shift, at discharge or patient transfer. Handover This can lead to errors such as omissions, misunderstanding,
implies transferring responsibility for a patient, including and delays (Pothier et al, 2005; Sharit et al, 2008).
clinical aspects and legal accountability, to another person Meissner et al (2007) reported that 53% of Italian nurses are
(Cohen and Hilligoss, 2010). Considering that patient transfers unsatisfied with handover and that the lack of rooms dedicated
are frequent, these aspects become of primary importance in to handover in hospitals has a negative influence on quality of
information. In fact, if the handover process takes place in noisy
and crowded rooms, as often happens when no dedicated places
Paolo Ferrara, Nurse Tutor and Lecturer in Nursing, San are available, the risk of errors and misunderstandings is likely to
Paolo Bachelor School of Nursing, University of Milan, San increase.The literature suggests using a common methodological
Paolo Teaching Hospital, Milan, Italy, paolo.ferrara@asst-
framework for nursing handovers, such as the SBAR (situation,
santipaolocarlo.it
background, assessment, recommendations) to mitigate the such
Stefano Terzoni, Nurse Tutor and Lecturer in Nursing, San Paolo problems (Porteous et al, 2009; Yee et al, 2009; Bulfone et al,
Bachelor School of Nursing, University of Milan, San Paolo
2012; Toccafondi et al, 2012; Quattrin et al, 2014).
Teaching Hospital, Milan, Italy
Developing adequate communication skills will help improve
Salvatore Davì, Nurse, Milan handovers and decrease the risk of adverse events (Finke et
Alberto Bisesti, Head Nurse, Policlinico Teaching Hospital, Milan, al, 2008; Keller et al, 2013; Moore et al, 2013; Kourkouta and
© 2017 MA Healthcare Ltd

Italy Papathanasiou, 2014).

Anne Destrebecq, Associate Professor of Nursing, Department of The literature offers several tools for studying the quality of
Biomedical Sciences for Health, University of Milan, Milan, Italy handovers. Currently no tools are available in Italian to assess
Accepted for publication: July 2017 the quality of the handover process. Having a valid and reliable
tool in Italian would be the first step toward implementing

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 RESEARCH

adequate policies of patient safety involving handovers. The The Handoff CEX
Handoff CEX scale, introduced by Horwitz et al (2013) seems The scale includes two different forms, one for the nurse
quick and easy to use. An Italian translation following a proper giving the handover (Table 1) and the other for the receiver
methodology is needed as handover needs in Italy may be (Table 2).The first form includes six items investigating context,
different from those of the scale’s country of origin. organisation, communication skills, content, clinical judgement,
and human qualities.The second includes the same items except
Aims ‘content’, which is only applicable to the provider. Each area
This study aimed to produce and validate an Italian version includes indicators aimed at producing objective assessment;
of the Handoff CEX scale in a sample of medical and surgical in addition, an open question allows further considerations to
hospital units. It also aimed to investigate the quality of nursing be raised. All items are based on a Likert scale ranging from 1
handovers during different shift changes. Finally, it investigated to 9. Scores from 1 to 3 are ‘unsatisfactory’, 4 to 6 ‘satisfactory’,
the relationship between the results of the Handoff CEX 7 to 9 ‘very satisfactory’.
and the different characteristics of the nurses and the setting. Both forms also include a question investigating overall
impressions, as well as a score defining the degree of agreement
Materials and methods of the nurse undergoing evaluation with the results of the
Forward and back translations assessment. Finally, the tool comprises a section to be completed
Authorisation to begin the translation was obtained from the by the head nurse, which investigates demographic characteristics
authors of the original Handoff CEX scale prior to starting of the sample and the organisation of the ward.
the study (Horwitz et al, 2013). After obtaining consent and During every shift change, four assessments are carried
confirmation that no Italian version existed or was in production, out: two by the head nurse (one for the provider, one for the
the translation process began. receiver), one by the provider towards the receiver for evaluating
Two nurses holding certificates in English performed the the reception process, and one by the receiver towards the
forward translation independently and then agreed upon the provider for assessing the process.
Italian text; a teacher of English language back-translated the An observational, single-centre study was conducted. The
scale into English.The final version was approved by the original authors enrolled the head nurses of 10 different wards (medical,
author.This process ensured adherence to the original meaning surgical, paediatric, and mental health) as external evaluators;
of all items. Involving two people in the translation process they were instructed by means of a 20-minute presentation
was necessary to avoid any potential bias related to subjective on the aims of the study and how to use the scale. The nurses
interpretation of the items, or to the possibility of translating the involved in the assessment process were informed by their
scale using different synonyms.The teacher who back-translated respective head nurses at the end of each handover, in order to
the scale had never seen it before; this ensured objectivity in avoid the Hawthorne effect (adapting one’s behaviour when
the preparation of the text sent to the original author. under observation) (McCambridge et al, 2014).
Data were collected from 1 to 31 July 2016. A minimum of
Face and content validity three evaluations were performed in all hospital units, separated
The Italian version was evaluated by nine nurses (three academic by at least 7 days, and enrolling different nurses each time.
tutors also performing clinical activity, three nurses from hospital In order to investigate potential differences regarding quality
wards, and three head nurses). Based on their assessment, the of the handover process during the three shift changes, assessment
authors calculated the content validity index, which is a measure was performed in all units at each handover (morning-afternoon,
of content validity commonly used in validation studies. The afternoon-night, and night-morning).
index has two components, called CVI-I (regarding each of Exploratory factor analysis was used to study the internal
the items) and CVI-S (regarding the whole scale). structure of the scale. It is a statistical technique used for
The CVI-I is determined by the calculation of the evaluations assessing the ‘weight’ (called ‘loading’) of each item in defining
by a group of expert-specific experts evaluating how relevant the overall variability of the results. Prior to factor analysis,
the individual items of an instrument can be, on a scale of 0 (not the Kaiser-Meyer-Olkin value was calculated, in order to
relevant) to 10 (very significant). The CVI-S is calculated by ascertain whether the mathematical properties of data make
averaging the percentage of items classified as ‘relevant’ (score 6 them suitable for factor analysis.To understand if the loading
to 7) or ‘very significant’ (scores 8 to 10) (Polit and Beck, 2006). of each item is sufficiently high to justify its presence in the
A questionnaire based on the indications from Beaton et al scale, a cut-off point was calculated according to the method
(2000) was then handed out to the nine nurses, to investigate proposed by Stevens (Sun Park et al, 2002).
clarity, repetitiveness, and the need for changes to the scale. Homogeneity was investigated by means of Cronbach’s
alpha coefficient. Homogeneity is an extension of the
Ethical considerations correlation concept: if the items of the scales are strongly
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The study was conducted upon authorisation from the hospital correlated with each other, they are likely to have the same
management.The authors complied with the rules of the local meaning for all users; this suggests that the measures obtained
ethical committee, the principles contained in the Declaration through the scale are consistent across similar situations,
of Helsinki, and the Italian law on data protection.All data were which is the definition of statistical reliability (Norman
collected anonymously. and Streiner, 2014).

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 Table 1: Handoff CEX: assessment of the provider and the emission process (English version)
Setting (* not observed)
≥5 interruptions; noisy, chaotic 1 2 3 4 5 6 7 8 9 No interruptions; silent
Unsatisfactory Satisfactory Superior
Organization/efficiency (* not observed)
Disorganized; Rambling 1 2 3 4 5 6 7 8 9 Standardized sign-out; concise
Unsatisfactory Satisfactory Superior
Communication skills (* not observed)
Not face to face; Understanding not confirmed; 1 2 3 4 5 6 7 8 9 Face to face sign-out; Confirm
No time for questions; Responsibility for tasks Unsatisfactory Satisfactory Superior understanding; Elicits questions; Assigns
unclear; Vague language responsibility for tasks; Concrete language
Content (*not observed)
Information omitted or irrelevant; Omits clinical 1 2 3 4 5 6 7 8 9 Includes all essential information
condition; ‘to dos’ lack plan, rationale Unsatisfactory Satisfactory Superior describes clinical condition, ‘to dos’ have
plan, rationale
Clinical judgement (*not observed)
No recognition of sick patients; No anticipatory 1 2 3 4 5 6 7 8 9 Sick patients identified; Anticipatory
guidance Unsatisfactory Satisfactory Superior guidance provided with plan of action

Humanistic qualities/professionalism (*not observed)

Hurried, inattentive; Inappropriate comments re: 1 2 3 4 5 6 7 8 9 Focused on task, appropriate comments
patients, family, staff Unsatisfactory Satisfactory Superior re: patients, family, staff

Overall sign-out competence

Low 1 2 3 4 5 6 7 8 9 High
Evaluatee satisfaction with evaluation:
Low 1 2 3 4 5 6 7 8 9 High
Comments:
Horwitz et al, 2013 (reproduced with permission)

Results handover process, overall median scores were evaluated, obtained

Validation of the Handoff CEX Italian version by each item of the scale (Table 5).
Internal consistency (Norman and Streiner, 2014) was The highest median scores were found in the ‘content’ areas,
satisfactory (Cronbach’s alpha=0.79). The CVI-S, based on ‘clinical judgement’ and ‘human qualities’, while lower values are
the scores expressed by the nine expert nurses, was 0.96, thus highlighted in areas ‘context’,‘organisation’ and ‘communication
indicating good content validity.As regards the CVI-I, all items skills’.The overall evaluation was 6 (5.0-7.0), a value that can
had values >0.90, indicating satisfactory validity. be considered ‘satisfactory’.
After this step, the expert nurses were involved in a debriefing The scores were not related to specific work experience
regarding face and content validity, which did not lead to any (p=0.21) and total nursing staff (p=0.13). The overall scores
further comments or changes to the scale. were analysed (Table 6).
Exploratory factor analysis was conducted after checking The median rating of the evaluations of the nursing
sample adequacy, by calculation of the Kaiser-Meyer-Olkin coordinator was lower than the assessments made by the
value, which was 0.73. All factor loadings were above Steven’s providing and receiving nurses, but the assessments made by
cutoff (.37) and are shown in Table 3. the three categories of evaluators did not show statistically
significant differences, either in the overall assessment (p=0.12)
Descriptive analysis or in single items (p>0.05 for all domains).
The authors analysed 48 shift changes in surgical, medical, The overall median level of agreement between providers and
mental health, and paediatric units, with 192 total handovers. receivers was 7 out of 10, interquartile range (IQR)=[6.5;8.0].
The overall number of inpatients ranged between 9 and 32, An additional analysis was performed, to assess differences
(median=17.5 [15.0; 21.0]). For each handover between two between the overall scores in each unit.
nurses, the number of patients was 5 to 16, median=10 [8;12]. Only one ward had overall scores significantly higher than
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The median handover length was 17.5 [15;20] minutes. Table 4 the others (median 8.0 [7.0;9.0], p=0.03). To understand why,
shows the characteristics of the handovers. the authors analysed the single items and compared them to the
other units. Setting and organisation were the only two items
Analysis of the handovers with significantly higher scores (p<0.001 for both analyses).
In order to analyse in detail the most critical aspects of the Handovers between night and morning shifts showed the

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 RESEARCH

Table 2: Handoff CEX: assessment of the receiver and the receiving process (English version)
Setting (* not observed)
≥5 interruptions; noisy, chaotic 1 2 3 4 5 6 7 8 9 No interruptions; silent
Unsatisfactory Satisfactory Superior
Organization/efficienty (* not observed)
Disorganised; ill-prepared 1 2 3 4 5 6 7 8 9 Prepared for note-taking; takes
Unsatisfactory Satisfactory Superior notes

Communication skills (* not observed)

No interaction, no questioning; 1 2 3 4 5 6 7 8 9 Face-to-face sign-out; asks
no read-back; no acceptance of Unsatisfactory Satisfactory Superior questions; read-back of
responsibility for tasks; vague assigned tasks; accepts
language responsibility; concrete
language
Clinical judgement (*not observed)
No recognition of sick patients; 1 2 3 4 5 6 7 8 9 Sick patients recognised;
No request for anticipatory Unsatisfactory Satisfactory Superior anticipatory guidance
guidance requested
Humanistic qualities/professionalism (*not observed)
Hurried, inattentive; 1 2 3 4 5 6 7 8 9 Focused on task–appropriate
Inappropriate comments re: Unsatisfactory Satisfactory Superior comments re: patients, family,
patients, family, staff staff
Overall sign-out competence
Low 1 2 3 4 5 6 7 8 9 High
Evaluatee satisfaction with evaluation:
Low 1 2 3 4 5 6 7 8 9 High
Comments:
Horwitz et al, 2013 (reproduced with permission)

lowest scores (Table 7).The difference between the scores of the suggests that such results might be owing to the influence
three shift changes was statistically significant (Kruskal-Wallis of the relationships between peers within the nursing staff
test: p<0.001). (Bahreini et al, 2011, Horwitz et al, 2013). Furthermore, it
should be considered that head nurses often have greater clinical
Discussion experience than staff nurses, which allows them to easily assess
Improving the communication process in nurse handovers is a handover quality.
priority considering its impact on quality of care, risk reduction, In order to analyse the most critical aspects of the process it
and thus the safety of patients (Manser and Foster, 2011). was decided to assess the overall median scores in each domain.
The purpose of this study was to validate the Italian version The high scores observed in the areas of ‘content’, ‘clinical
of the Handoff CEX, which lays the foundation for a more judgement’ and ‘human qualities’, provides important and
structured way of analysing the quality of nursing handovers. reassuring information about training and professionalism of
The Italian version of the scale showed satisfactory internal the nurses, being scarcely affected by setting. In particular, they
consistency; excluding the items one by one, the Cronbach’s confirm the mastery of core theoretical knowledge (‘content’
alpha remained above 0.75, which suggests homogeneity and area and ‘clinical judgement’) and the fundamental prerequisites
therefore reliability of the instrument. for a helping profession (the ‘human qualities’ area).
Factor analysis also confirmed that the scale has a one- The lowest scores were found in the areas of ‘context’,
dimensional structure, i.e. no sub-scales: each of the items ‘organisation’ and ‘communication skills’.
contributes in an important way to properly describe the The complexity of the relationship that is established between
characteristics of the handover. Finally, considering the excellent health professionals, particularly nurses and patients, makes it
face and content validity, the Italian version of the Handoff CEX necessary to develop appropriate communication skills. Effective
can be considered valid and reliable for the evaluation of nursing communication is key to developing feelings of trust and mutual
© 2017 MA Healthcare Ltd

care delivery and therefore applicable to the Italian setting. respect and contributes to the improvement in adherence to
The overall scores regarding quality of handovers were therapies and care plans (Ku and Minas, 2010) and nursing
satisfactory but not excellent. However, the median scores outcomes (Charlton et al, 2008; Tay et al, 2011). Having good
provided by head nurses were slightly lower than those expressed communication skills cannot be considered exclusively as an
by nurses. This finding is consistent with the literature, which innate characteristic and individual predisposition. It must

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 Table 4. Characteristics of the handovers studies (Adib Hajbaghery and Shahsavarloo, 2014; Zamanzadeh
et al, 2014) that show a lack of adequate communication skills
Variable n (%)
among nursing staff.
Type of hospital unit
‘Context’ area scores were the lowest; it is important to
Surgical 27 (56.25) have a peaceful and appropriate place for the handover process;
Medical 12 (25.00) however, such a place is not always available in hospital units.
Mental health 6 (12.50) This investigation confirms that most handovers take place in
Paediatric 3 (6.25) the nurses’ stations, which are often chaotic, with interruptions
Shift and people coming and going.
Morning–afternoon 37 (77.08) Finally, reflection is needed to consider why a low score was
obtained in the ‘organisation’ area. Poor organisation of the nurse
Afternoon–night 2 (4.17)
during handovers, for example because of the lack of a structured
Night–morning 9 (18.75)
method and the short time available to prepare and discuss
Place handovers, may affect the quality of the information provided.
Nurses’ station 152 (79.17) The study’s results show that the time devoted to handover
Ward kitchen 20 (10.42) is quite limited, owing to the large number of patients whose
Meeting room 12 (6.25) handovers must be planned and given. This finding is in
Dedicated room 8 (4.17) agreement with the literature (Meissner et al, 2007; O’Connell et
Overall experience as a nurse al, 2008) and highlights the fact that the nurse must necessarily
develop the capacity to transmit the main and fundamental
<1 year 6 (3.13)
aspects of the patient’s care in the shortest time possible and
1–2 years 12 (6.25)
in the most appropriate way.
3–5 years 54 (28.12) In the only unit in which the handover were provided in a
>5 years 120 (62.50) dedicated room, separated from the department, and reserved
Experience in the current ward solely for nurses and social and health workers, significantly
<1 year 12 (6.25) higher scores in the context and organisation areas were
1–2 years 24 (12.50) achieved; this can also be explained by the fact that the unit has
3–5 years 64 (33.33) recently adopted the SBAR method. Based on the findings, the
authors believe that both the SBAR method and the presence
>5 years 92 (47.92)
of rooms dedicated to handovers made the difference.
The scores obtained in the three assessment times showed
Table 5. Overall median scores significant differences. The handover between the night and
Item Median IQR the next morning got much lower valuations from a practical
Setting 4 3.0–7.0 point of view, these findings highlight a potential problem
Organisation 5 4.0–8.0
because the current shifts scheme requires that nurses return
to the morning shift after rest days. As there may have been
Communication skills 6 4.0-–8.0
new admissions during the nurses’ rest days, they are likely to
Content 7 5.0–9.0
take charge of many patients with complex conditions, with
Clinical judgement 7 5.0–9.0 whom they are not familiar.
Human skills 7 5.0–9.0 In this situation, the nurses need accurate and complete
Overall assessment 6 5.0–7.0 information, but according to the authors’ observations during
IQR: Interquartile range this study, they are likely to get low-quality handovers from
colleagues from the night shift, who have worked for several
Table 3: Factor loadings of the items consecutive days. The authors could not find any data in the
Item Loading literature regarding this aspect of handover, so this is an area
Setting 0.39671 for future research.
Organisation 0.38893
Communication skills 0.62995 Limitations
Content 0.78010
This was a single-centre study; the sample size was limited,
although larger than the original study (Horwitz et al, 2013)
Clinical judgement 0.91182
Further investigations are needed on larger samples in the
Human skills 0.84276
Italian setting.
© 2017 MA Healthcare Ltd

instead be supported and strengthened through targeted training Conclusions

during the academic career of the student, who should undergo Nursing communication, especially during the handover
continuous update training during their career (Wikström and between work shifts, is a crucial aspect of nursing practice in
Svidén, 2011).The results of this work seem to agree with other all clinical settings.

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 RESEARCH

Table 6. Handoff CEX scores

Item Evaluator
Head nurse IQR Provider nurse IQR Receiving nurse IQR p
Setting 3.5 3.0–5.0 4.0 3.0–6.0 4.5 3.0–6.0 0.11
Organisation 5.0 4.0–8.0 6.0 6.0–7.0 6.0 6.0–8.0 0.23
Communication skills 6.0 5.0–7.0 7.0 6.0–8.0 7.0 6.0–8.0 0.12
Content 6.0 5.0–9.0 * 6.5 6.0–9.0 0.56
Clinical judgement 6.0 5.0–7.0 7.0 6.0–8.0 7.0 6.0–8.0 0.47
Human skills 7.0 6.0–8.0 7.0 6.0–9.0 7.0 7.0–9.0 0.10
Overall assessment 6.0 5.0–7.0 7.0 6.0–7.0 6.5 6.0–7.0 0.12
IQR=Interquartile range
* = this item was not assessed by the provider nurse, according to the structure of the scale

This study has provided the Italian nursing community Table 7. Median scores at each shift change
with a tool that can help evaluate handovers; further work Shift change Median IQR
is needed to confirm how useful the Handoff CEX scale Morning–afternoon 7 6–7
is helping to build safer care environments. Future research
Afternoon–night 6 5–7
should take into account the assessment of health records in
Night–morning 5 5–6
use, the data entered and the quality of written notes required
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CPD reflective questions

■■ In your opinion, how does the handover process affect quality and safety of nursing care?
■■ What are the most critical aspects that deserve investigation and possibly interventions in your clinical setting?
■■ How could these issues be brought to the attention of the nursing staff?

IV THERAPY
Quarterly supplement covering all aspects
of IV therapy in nursing from infusion
therapy to vascular access and patient care
The British Journal of Nursing (BJN) IV Therapy Supplement aims to promote evidence-
based practice and the provision of high quality patient care. We welcome unsolicited
articles including literature reviews, care studies and
original research in all areas of IV therapy. To contribute
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to the supplement or to enquire about how to become

a peer reviewer in this area, contact us at bjn@ National Infusion and
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