Effectiveness of Handoff Educational Program on Nurses Interns’ Knowledge, and Communication Competence

With the growing complexity of health care, the ability to communicate becomes essential within the health team members. Health care organization has great expectations for new graduate nurses to communicate skillfully while promoting safe patient care. Student nurses interns may lacked experiences with important communication skills and are fearful of making mistakes which may affect patient safety. One way to improve handoff communication skill among nurses interns is through education. This study was intended to examine the effectiveness of handoff educational program on nurse’s interns’ handoff knowledge, and communication competence. Quasi experimental study design was utilized: The study was conducted in intensive care units which affiliated with Kaser El Ainy hospital where nurses interns were trained. Study sample composed of 30 nurses interns who were undertaking their internship year between 2016-2017. Data were collected through utilizing Handoff knowledge questionnaire that was developed by the researcher and Handoff communication competence observational checklist developed by [1] and modified by the researchers to measure hand-off communication competence of nurses interns during the process of bedside handover. Results revealed that there were statistical significant and marked improvement in nurses interns’ levels of handoff knowledge dimensions as well as statistical significant differences in their mean scores of handoff communication competence during different periods of assessment. The current study provide evidence that handoff educational program enhance nurses interns handoff communication competence. Handoff communication skills should taught formally during nursing academic education concerning the way that information is given, verified as well as all handoff communication competencies during process of patient bedside handoff. Future researches with larger sample sizes and multiple settings are recommended to substantially evaluate the effectiveness of educational program on handoff communication competencies.

Many types of patient handoffs are introduced in the literature, including nursing shift changes; reporting of patient's conditions by physicians; reporting by staff leaving the unit for a short time; nursing and physician handoff from the emergency department to inpatient units, other hospitals, and critical patient laboratory results sent to physician offices. Recently many other handoff forms have been developed, such as the bedside report and the tape-recorded handoff [17].
In reviewing the literature related to the patient handoff process, it is important to consider communication competence. By understanding what behaviors influence the quality of the patient handoff, nurses can know how to enhance their competency in handoff communication regardless of how an organization standardizes the interaction. Improving the overall communication competence of nurses could lead to effective handoffs and reduced communication-related patient care errors. Communication competence is a core concept in interpersonal communication research and it can be defined as the knowledge of appropriate communication patterns in a given situation and the ability to use the knowledge. Competent communication includes information exchange which focuses on information seeking, giving and verifying as well as socio-emotional communication. [18] [19].
Information giving or provision is being related to the detail given in response to a direct question or offered without prompt. While information seeking is the ability to ask questions to get a more complete, accurate and current data of a patient's status at change of shift. The information verifying consists of clarifying, repeating, summarizing and anticipating. These behaviors are important to the handoff as a method of reducing the risk of miscommunication by assuring understanding. The socio-emotional communication is another one component of communication competence that focuses on enhancing trust relationship, concern, and warmth [18].
Nursing students should be prepared for and learn the process of effective communication that promotes patient safety. The knowledge and skill to carry out a handoff report may be briefly addressed in the classroom or simulation laboratory setting but is mastered from the observation of mentors and peers [20]. Moreover students interns are exposed to multiple clinical sites and witness variability in handoff practices among different institutions. Following graduation, new nurses rarely receive formalized handoff education. Instead, they often learn this important safety skill by modeling equally unskilled peers. This inconsistency in hand off preparation for student nurses and new nurses creates a latent safety risk [10]. Though there is recognition that handoff communication skills are essential components of undergraduate nursing education. There is little research regarding the best methods for providing this education on nursing students. The process to learn handoff communication is often unpredictable and dependent on clinical experiences. Safety education, including handoff education, may help build more highly reliable health care

Research Aim& Hypothesis
The current study aimed to examine the effectiveness of handoff educational program on nurse's interns knowledge, and communication competence. This research was designed to test the hypotheses that there is significant difference in the knowledge regarding handoff, and communication competence among nurse's interns before and after the participation in handoff educational program.

Design
Quasi -experimental study design was utilized to examine the effect of handoff educational program on nurse's interns' handoff knowledge, and communication competence.

Setting
The study program was conducted in all intensive care units with different specialties which affiliated with Kaser El Ainy hospital where nurse's interns were trained.

Sample
Study sample composed of 30 nurses interns who were undertaking their internship in intensive care units during the academic year 2016-2017. According to internship rotation plan, one group of nurses interns who start their training in ICU at the beginning of internship year and who complete the educational program sessions successfully as well as different follow up periods of the program were constitute the study sample.

Tool
The following tools were utilized as follows:

Demographic Data Sheet
Demographic data sheet: was developed by the researchers and it included background characteristics of nurses interns, such as: age, sex, type of education before joining the faculty (secondary school degree or technical institute degree), previous handoff knowledge and previous work experiences during their study years.

Handoff Knowledge Questionnaire
Handoff knowledge questionnaire was developed by the researchers based on the literature review [25] [26] [27] [28], to assess nurse's interns' knowledge about handoff. It consisted of (15) Multiple-choice questions, covering the following: Handoff definition and related concepts (3 items), importance and benefits of handoff (3 items), components of handoff and communication competence (3 items) methods and structure of handoff (3 items), and Handoff communication tools (3 items).
The scoring system for the questionnaire sheet consisted of score (one) for correct answer and (zero) for the wrong answer for Multiple-choice questions. The scoring levels were arranged as follow 60% and more for satisfactory knowledge. Less than 60% is for unsatisfactory knowledge [29]. It was utilized during different periods of assessment (pre-program, immediately after program and 3 months later)

Handoff Communication Competence Observational
Checklist Handoff communication competence observational checklist was developed by [1] and modified by the researchers to measure hand-off communication competence of nurses interns at the patient bedside handover as a one-way report from the outgoing to the incoming nurses interns. It contains the following subscales: information giving (10 items), facilitating information seeking (5 items), information verifying (3 items) and socio-emotional communication (7 items). The scoring system was as follows: 1 for done and zero for not done. The total score is 25, score 14.9 which represents (59.9%) indicates low competence, score from 15-18.5 which represents (60-74%) indicates moderate competence and finally score 18.9 which represents (75% and more) indicates high competence. It was utilized during different periods of assessment (pre-program, immediately after program and 3 months later).

Tool Reliability and Validity
Handoff communication competence observational checklist was tested for its reliability, the measure demonstrated good internal consistency (α =.95). The tools contents were developed and tested for its content validity through five expertise from nursing administration department. Based on their recommendations the necessary modifications were made.

The Pilot Study
A pilot study was conducted on 10 percent of study sample in order to test the clarity and validity of the study tools content, add or omit questions and assess time needed to respond to each questionnaire. Necessary modifications were done.

Ethical Consideration
Official permissions were obtained from hospital's director and nursing director of the previous selected hospital to conduct the study at the selected units. They were assured that the data is confidential and used only for research purposes. The researchers ensured that the correct procedures were undertaken concerning informed consent, autonomy, anonymity and maintenance of the subjects confidentiality.

Procedure
Prior to implementation of the handoff educational program, an official permission was obtained from the nursing supervisors of the selected units. This was intended to facilitate data collection and to explain study purpose. At the beginning of the internship year, nurse's interns were invited to participate in the program. The researchers explained the study purpose and procedures for the selected sample. Student nurses were further informed that the participation was voluntary and that study findings would be presented group wise and no individual would be recognized.
A knowledge test questionnaire was then handed to nurses interns on their work place to measure their knowledge about handoff and related concept using the developed handoff knowledge questionnaire. Because incoming nurse interns play little role in bedside handoff, observations of the students interns as outgoing in different shifts during patient bedside handoff was conducted to measure their communication competence while they report to incoming students interns through utilizing handoff communication competence observational checklist. So each nurse intern was given the opportunity to be observed as outgoing nurse through 3 intermittent observation. Arrangement with head nurses of the selected units was done by the researchers to allow outgoing interns to report incoming one. The preprogram data were carried out from 1 st of October to mid of November 2016.
After collecting pre-program data, the studied sample was divided into two groups according to their shift rotation and the program educational sessions were held twice a week. Each session lasted an hour, and the total educational sessions for the program were 5sessions. Contents of the program sessions were as follows: Handoff definition and related concepts (1 st session), importance and benefits of handoff (2 nd session), components of handoff and communication competence (3 rd session) methods and structure of handoff (4 th session) and Handoff communication tools (5 th session). These sessions were followed by supervision of nurse's interns in their clinical areas covering different work shifts in order to provide each nurse with support, and help them to use new knowledge. Different teaching and learning methods were used during conducting program: lecture, group discussion, demonstration, and work in small groups. The program educational sessions were carried out from 1 st of December 2016 to 1 st of January 2017.
To assess the immediate impact of the program on nurses interns handoff knowledge and communication competence, the previous instruments were utilized immediately after the program started from the mid of January 2017to end of February 2017. In addition to measure nurse's intern's retention of handoff knowledge as well as handoff communication competencies, the previous questionnaires were utilized 3 months after program implementation started from June 2017 to mid of July 2017.

Statistical Design
The collected data was scored, tabulated by using statistical package for the social science (SPSS) program version 20 and analyzed by using the following tests: frequencies and mean and standard deviation were used as measures of central tendency and dispersion respectively for qualitative data Test of significance was performed to test study hypothesis (F test). Comparison between two groups and more was done using Chi-square test. Correlation between variables was evaluated using Pearson's correlation coefficient (r). Significance was adopted at p<0.05 for interpretation of results of tests of significance. Data in table 1 showed that the majority of studied sample (96.7%) was in age group ranged between 22-less than 24 years, as well as the highest percentage of them (63.7%) were male. Regarding their type of education data in the same table showed that the majority of them (83.3%) were graduated from secondary school. It is clear also that 56.7% of studied sample did not have previous work experiences.   The above figure showed that the highest percentage of nurses interns were working day shift during different periods of assessment. and (93.3%, 50%, & 56.6%) respectively (p=.000*). Also it was clear that 100% of nurses interns scored satisfactory level3 months post program relative to pre and immediately post program regarding the following three dimensions (importance and benefits, methods and structure of handoff and handoff communication tools) and all differences were statistically significant. Data figure 4 showed marked improvement in total handoff knowledge levels among nurses interns during different periods of assessment as 90% of nurses interns had satisfactory score immediately post program with further improvement 3 months post program as100% scored satisfactory level relative to only 53.33% in pre-program.   It is clear from figure 6 that there was a marked improvement in nurse's interns levels of total handoff communication competences, it was shown that nurses interns had generally high score in the preprogram period (63.3%) and none of them scored low during different periods of assessment. Further improvement was seen 3 months post program as 100% of them scored high competencies  4 that there was only a statistical significant correlation immediately post program between nurses interns' total handoff Knowledge and total communication competencies (r=.319, p= 002*). As well as a statistical significant correlation between total handoff Knowledge and both Information giving and Socio-emotional communication dimensions (r=,329, p=0.02*, r=.356, p=0.04*) respectively. While no any statistical significant correlation was found in pre-program and 3 months post program implementation. The above table illustrated that there was no statistical significant differences between night and work shift nurses interns regarding their mean scores of handoff communication competencies dimensions immediately post program, although nurses interns in night shift had highest mean scores compared to those in day shift, it is not proved to be statistically significant. Data in the same table showed a statistical significant differences between day and night shift nurses interns mean score only in information seeking dimension 3 months post program as night shift had highest mean scores compared to those in day shift, (p=.024 *).

Discussion
Dynamic and complex clinical environments present many challenges for effective communication among health care providers. The goal of nursing handoff is to communicate and exchange accurate, relevant and up-to-date clinical information about the patient which is necessary for continuity of care. Clinical handoff is one of the most important issues to consider when ensuring the continuity of patient care and safety. An effective handoff supports the transition of critical information and continuity of care and treatment [17]. The practice of handover between health professionals is an everyday practice, but a potentially risky aspect of patient care. Miscommunication of information can result in inadequate or unsafe care [5]. A nursing handoff, or handover, is a complex communication process that transfers essential information, responsibility, and accountability for the care of a patient from one nursing professional to another. Handoff education has been identified as a quality and safety education in Nursing (QSEN) pre-licensure competency [30].
The current study results support the research hypotheses which revealed that, there is significant difference in the knowledge regarding handoff, and communication competences among nurses' interns before and after the participation in handoff educational program. Regarding nurse's intern's levels of handoff knowledge dimensions during different periods of assessment, the current study results revealed that there was statistical significant and marked improvement in nurse's interns' levels of handoff knowledge dimensions during different periods of assessment regarding most of handoff knowledge dimensions. As the majority of studied sample had satisfactory score 3 months Interns' Knowledge, and Communication Competence post program compared to preprogram and immediately post program period. This result is consistent with [17], who found a significant difference at pre and post educational session regarding nurse's handoff knowledge and they added that, inadequate handoff of patient information carries significant risks for individual clinicians, their organizations and for their patients. So a Sufficient and relevant information through educational sessions should be exchanged to ensure patient safety. More over without handoff education, the nursing students in this study lacked awareness of the importance and benefits of handoff, methods of handoff as well as components of handoff and communication competence [10].
From the investigators' point of view, engaging nurses interns in handoff educational program had a positive impact on increasing their knowledge as they become aware about essential concepts of handoff, methods and structures, in addition they gain knowledge about importance of proper handoff for them and for their patients. Moreover they became knowledgeable about socio-emotional communication as a core concept in interpersonal communication.
Regarding the nurses intern's handoff communication competencies during different periods of assessment the present study revealed that there was a statistical significant differences in nurses interns mean scores regarding most of dimensions of handoff communication competencies 3 months post program relative to pre and immediately post program period. In addition there was a marked improvement in their levels of total handoff communication competences 3 months post program as all of them scored high competencies. From the researchers' point of view this result support the positive effect of the program as the knowledge they gained in the educational program help them to practice handoff communication well. In the same issue [20] found that after implementation of handoff educational sessions the nursing students had a better grasp of the background and rationale for an effective hand-off report. As a result, students began to recognize pertinent critical health information that needed to be communicated to their nurse. Nursing students also conveyed feelings of confidence and empowerment in the performance of hand-off communication. This result is consistent with [17], as they reported a statistical significant difference at pre and post educational session regards the overall quality of handoffs received described as excellent or good. This result is expected after nurses know, what, how and when the right handoff and its effect on quality of patient care applied at educational session.
Moreover when the dimensions of handoff communication competencies were investigated during different periods of assessment, study results showed statistical significant differences in most of related dimensions (information giving, seeking and verifying) 3 months post program relative to pre and immediately post program. In this respect [31] reported that enhanced training and systems for effective and safe handoff are essential in maintain high standards of continuity of care. In addition, [21] Found that nurses scores increased significantly in handoff after the study intervention in terms of patient safety through updating their caring program, maintaining the continuity of care, and improving the quality of inter-shift information communication. On the same line, [18] stated that nursing handoff is a critical issue in a patient's care that happens two to three times every day. Handoff must facilitates a respectful, concerned, comprehensive and accurate dialogue between nurses rather than a one-way nursing handoff report offers an opportunity for nurses to collaborate, providing different perspectives about patient needs, identifying areas of concern, and perhaps preventing mistakes based on misinformation or inaccurate information.
From the researchers' point of view engaging nurses in handoff educational program increased their competencies regarding explaining treatment needed by the patient, endorsing services needed for the patient, providing relevant historical information about the patients, and answering the other nurse's questions thoroughly. In addition during bedside handoff the outgoing nurse interns encouraging the incoming one to ask questions and seek information, answering questions of incoming nurse related to the patient's needs. As well as reviewing important or complex information to make sure it correctly understood and making sure that all explanations and directions were clearly understood. In this respect [17], reported that nursing handoff is to communicate and exchange accurate, relevant, and upto-date clinical information about the patient that is necessary for continuity of care. In addition, [32] noted that the handoff involves both a transfer of knowledge as well as authority and responsibility.
Regarding socio-emotional communication as one dimension of communication competence, the current study results revealed increased mean scores of nurse's interns immediately post program and 3 months later. In this respect, [20] stated that collaborative inter professional communication are essential elements of the transfer of crucial patient information and the socio-emotional communication is another one component of communication competence that focuses on fostering warmth, trust, and concern during handoff [18].
Regarding the correlation between nurses' interns total handoff knowledge and communication competencies dimensions during different periods of assessment, results of the current study revealed that there was only a statistical significant correlation immediately post program between nurses interns' total handoff Knowledge and total communication competencies. As well as a statistical significant correlation between total handoff Knowledge and both information giving and socio-emotional communication dimensions. From the researcher's point of view, this result can be explained as, the training program has its immediate positive effect and nurse's intern's starts to apply the knowledge they gained which was reflected on their communication competence, and they recognized pertinent critical health information that needed to be communicated to their peers. In the same issue [30] concluded that nursing students performed significantly better when providing and receiving handoff after they gain handoff knowledge in training program. Additionally, [33] has described the positive effect of handoff training in handoff receiver skills. Without handoff education, the nursing students lacked awareness of the importance of an active handoff recipient in creating a shared mental model. Consistently with the current research result [34] describes the necessity of both provider and receiver actively participating in the co-construction of the oncoming caregiver's understanding of the patient in order to promote patient safety. In the same issue [30] found that the nursing handoff educational training program improved handoff communication skills in nursing students.
When mean scores of nurses interns regarding hand off communication competencies were investigated in relation to work shift as work related variable, results of the current study revealed that there was a statistical significant differences between day and night shift nurses interns mean score only in information seeking dimension 3 months post program as night shift had highest mean scores compared to those in day shift. This result is contradicted with [35] who found that nurses who worked 8 hours shift report proper handoff quality than those work 12 hours shift. From the researcher point of view multiple work environment in day shift might affect the handoff practice as multiple interruptions, noisy environment and medical round which causing multiple distraction and leads to sharing of information quickly which in turn lead to incomplete and inaccurate report.
Regarding the relationship between nurses intern's handoff knowledge and communication competencies and their demographic variables, the current study revealed that, there was only a statistical significant relationship between handoff communication competencies and nurses intern's previous handoff knowledge while no other relationships were found between study variables and other demographic variables. From the researchers' point of view this could be related to that the highest percentage of studied sample reported that they gain previous handoff knowledge during undergraduate course and in clinical orientation which in turn affect their overall handoff communication competencies. This result is consistent with [36] who conclude that there was no relationship between nurses handoff practice and their demographic variables as age, gender, educational statues and experiences.

Conclusion
Results of the current study revealed that there was statistical significant and marked improvement in nurse's interns' levels of handoff knowledge dimensions as well as statistical significant differences in their mean scores of handoff communication competence during different periods of assessment. The current study provide evidence that handoff educational program enhance nurses interns handoff communication competence.