implementing EBP

September-October 2017 • Vol. 26/No. 5 297

Kathryn R. Stewart, BSN, RN, is Registered Nurse, Shock and Trauma ICU, Erlanger Health
System, Chattanooga, TN.
Kelli A. Hand, DNP, MBA, RN, is Lecturer, School of Nursing, University of Tennessee,
Chattanooga, TN.

SBAR, Communication, and Patient
Safety: An Integrated Literature


n the landmark Institute of
Medicine report To Err is
Human, editors Kohn, Corri –

gan, and Donaldson (2000) brought
attention to the epidemic of med-
ical errors occurring in the U.S.
healthcare system. They concluded
the root cause of these errors often
could be traced to faulty systemic
processes. Errors in communication
have been a major source of miscal-
culation and misdirection in health
care. According to The Joint Com –
mission (2015), communication
errors have been among the top
three leading root causes of report-
ed sentinel events every year since
2004. Times of patient handoff may
contribute to informational gaps
due to the frequency with which
these reports occur and the high-
stakes nature of the information
being exchanged (Staggers & Blaz,

The objective of this systematic

review is to analyze literature
addressing use of the Situation-
Back ground-Assessment-Recom –
mendation (SBAR) framework to
determine its effectiveness during
patient handoff communication
between healthcare pro viders. The
review approach allowed inclusion
of multiple variables and diverse
methodologies, making it the most
suitable method available for ana-
lyzing the literature pertaining to
SBAR’s impact on communication
and patient safety (Torraco, 2016).

The Joint Commission (2008)

initially defined handoff as “the real-
time process of passing patient-spe-
cific information from one caregiv-
er to another, or from one team of
caregivers to another for the pur-
pose of ensuring the continuity and
safety of a patient’s care” (p. 65).
Despite their purpose of providing
necessary information for delivery
of safe patient care, patient hand-
offs appear to be prone to errors
related to frequent communication
barriers (Mardis et al., 2016).
Common barriers to effective hand-
off communication include the
hierarchical nature of health care,
organizational culture, differences
in the practiced communication
style of healthcare professions, lack
of a standardized process, and an
increasingly complex care environ-
ment (Daniel & Wilfong, 2014; The
Joint Commission, 2005, 2012). In
addition, the varying parties and
the large amount of complex infor-
mation included in handoff reports

frequently contribute to informa-
tional gaps and omissions in the
handoff report that can lead to sen-
tinel events and patient harm
(Staggers & Blaz, 2013).

To reduce communication errors
during handoff, SBAR was created
by U.S. Navy personnel as a method
for conveying critical information
in an effective, timely, and succinct
way (Curry-Narayan, 2013). Em –
ployed primarily in high-risk situa-
tions of the Navy’s nuclear subma-
rine industry, the SBAR communi-
cation tool enabled all users, regard-
less of the level of command, to
communicate via a common struc-
ture. Clinical staff at a Kaiser Perma –
nente organization in Colo rado
adapted the SBAR communication
template for use in health care
(Institute for Healthcare Improve –
ment, 2016). Following initial use
between nurses and physicians, the
SBAR template also has been used to
guide handoffs in the nurse-to-
nurse shift change report and inter-
professional patient reviews (Raiten
et al., 2015; Vardaman et al., 2012).

Kathryn R. Stewart
Kelli A. Hand

The SBAR (Situation-Background-Assessment-Recommendation)
tool was introduced to health care in 2002 to guide communica-
tion of patient care information. Evidence of an integrated literature
review indicates SBAR is an effective intervention for patient safety
through improved communication.

Instructions for Continuing Nursing Education Contact Hours appear on page 304.

September-October 2017 • Vol. 26/No. 5298

Introduction of the SBAR tool has
brought regularity and predictabili-
ty to handoff communications and
has been endorsed by The Joint
Commission (2012).

The combined search terms of

SBAR, communication, and patient
safety were entered into PubMed,
CINAHL Complete, and Cochrane
Library databases to find peer-
reviewed, English-language articles

published 2012-2017 that evaluated
the effect of SBAR use on patient
safety and communication between
healthcare providers. Additional
exclusion criteria included overlap-
ping articles between databases,
studies still in progress with no avail-
able results, articles describing only
the implementation process of
SBAR, articles assessing SBAR use
between non-healthcare profession-
als, and editorials. After application
of the exclusion criteria, 21 articles
were retained for this review. The

included publications were analyzed
for findings about SBAR use, com-
munication, and patient safety.

Results of the empirical studies

were entered in a table to identify
recurring themes regarding SBAR
use and the effect on communica-
tion and patient safety (see Table 1).
Four primary themes were identi-

Studies and Themes

Author/Date Methods Results Setting/Sample LOE
Blom et al.,

Pre/post-SBAR questionnaire
to evaluate healthcare
professionals’ communication

SBAR increased efficient oral communication
among healthcare workers (p=0.001). SBAR
perceived by healthcare professionals as an
effective and efficient way to structure patient
reports. Written comments noted SBAR use
facilitated improved patient safety.

Two 26-bed
hospital surgical
wards in southern

Level IV

Cornell et al.,

Observations of shift reports,
IDR before and after
introduction of paper SBAR
then electronic SBAR forms

Regarding shift reports: post-SBAR, time to
complete shift report decreased with paper
and electronic SBAR (p<0.01). Higher volume of information also exchanged with use of SBAR (p<0.01). Regarding IDR: post- SBAR implementation, patient reviews were more consistent and shorter (p<0.01). Suburban hospital in mid-southern United States n=36 RNs, IDR patient reviews Level IV De Meester et al., 2013 Pre/post-SBAR study using review of patient records for SBAR items during 48 hours before adverse event; questionnaires measuring nurse-physician collaboration, rate of SAEs performed Post-SBAR implementation, unplanned ICU admissions increased from 13.1/1,000 to 14.8/1,000 (p=0.001); unexpected deaths decreased (p<0.001). No difference in cardiac arrest team calls noted. Perception of effective communication and collaboration increased. Using SBAR, nurses were more willing to call physicians. Increased unplanned ICU admissions most likely resulted from nurses identifying patient changes earlier, leading to more ICU admissions and fewer unexpected deaths. 16 medical- surgical wards 5 ICUs (491 beds) of Antwerp University Hospital (Belgium) n=425 questionnaires, 207 SAE patient reviews Level IV Fabila et al., 2016 Pre/Post SBAR-PETS survey measurements of perceived sufficiency, clarity, accuracy of communication Proportion of personnel indicating exchanged information was frequently or always sufficient increased (p<0.0001). The proportion of responses indicating received information was concise/clear increased 70.5% (p<0.0001). Proportion of participants who rarely or never found information received in report differed from the following clinical assessment increased 43.2% (p<0.001). 16-bed unit of KK Women’s and Children’s Hospital (830-beds, Singapore) n=52 personnel (RNs and pediatric intensivists) Level IV continued on next page September-October 2017 • Vol. 26/No. 5 299 SBAR, Communication, and Patient Safety: An Integrated Literature Review TABLE 1. (continued) Studies and Themes Author/Date Methods Results Setting/Sample LOE Fay-Hillier et al., 2012 Students educated on SBAR followed by use in simulated setting in which they assessed a patient then reported to each other; post-SBAR qualitative peer evaluation/ team debriefing to assess effect of SBAR on perceptions of communication, patient safety Peer feedback indicated students considered simulation experience with SBAR assistive in improving their communication and collaboration skills. All participating students indicated using SBAR tool for report helped them focus on patient safety. Drexel University College of Nursing and Health Professions (Philadelphia, PA) n=9 nursing students Level IV Joffe et al., 2013 RCT in simulated on-call setting: nurses contacted physicians regarding six adapted cases. Three cases were handled without SBAR (control), three with SBAR. Communication regarding specific situation cues and background cues was evaluated. 92 telephone calls reviewed. Most nurses reported situation cues (SBAR group 88%, control group 84%, p=0.6), but not background cues. Fewer background cues provided in SBAR cases (14% SBAR, 31% control, p=0.08). Simply providing SBAR forms did not ensure communication of key information in after-hours telephone calls. University of Texas Health Science Center n=22 nurse- physician pairs Level II Martin & Ciurzynski, 2015 NPs, RNs conducted joint patient assessments, discussed findings using SBAR structure; Huddle, SBAR, and Communication Observation Tool (HSCOT) and pre/post measurements via Collaboration and Satisfaction About Care Decisions – PEDS ED (CSACD) survey to assess teamwork, communication, RN job satisfaction Joint patient evaluations occurred 83% of the time with minimal interruptions; 83% of RNs and 78% of NPs reported having great experience in joint evaluation, SBAR huddle. Mean communication score between RNs and NPs improved post-SBAR with corresponding improvements in perception of communication (no p-values reported). RN job satisfaction improved post-SBAR (no p-value reported). Pediatric emergency department in academic medical center, western New York n=32 personnel (RN and NP), 36 patient encounters Level IV McCrory et al., 2012 Pre/post-SBAR scoring of simulated handoff reports of decompensating pediatric patients given by pediatric interns to rapid responder; two blinded reviewers assessed recordings for information inclusion, information order, elapsed time of handoff. Mean score of handoffs increased in post- intervention scenarios (p<0.001); current situational information prioritized above background information in post-intervention scenarios (p<0.001); duration of handoff increased in post-intervention scenario (p=0.004), while elapsed time from start of handoff to time intern stated essential content item decreased post-SBAR (p<0.001); Pearson correlation coefficient between reviews 0.94 (p<0.001) Johns-Hopkins University Hospital Simulation Center n=26 pediatric interns, 52 handoff recordings Level IV Mitchell et al., 2013 Pre/post SBAR measurements via observation and blinded assessments of senior resident presentations at weekly surgical conferences using a validated assessment tool, faculty assessors with sufficient interrater reliability, survey assessments of user satisfaction, multiple-choice questionnaires assessing educational outcomes of conference attendees Presentation quality improved significantly post-SBAR (p=0.002), resulting in clearer delivery of key information; user satisfaction surveys indicated satisfaction with SBAR structure (all scores ≥ 3 on 5-point Likert scale); additional free-text comments universally indicated presenters considered SBAR format simple to use, helpful in structuring presentations; educational outcomes of attendees improved post-SBAR (p<0.0002). Oregon Health & Science University n=66 senior resident presentations/ user-surveys, 224 quality assessments, 1,247 multiple choice questionnaire responses Level IV continued on next page September-October 2017 • Vol. 26/No. 5300 TABLE 1. (continued) Studies and Themes Author/Date Methods Results Setting/Sample LOE Nagammal, Nashwan, Nair, & Susmitha, 2017 Validated Handover Evaluation Scale to assess current nurse perception of SBAR handover structure 95.1% of nurses agreed SBAR followed a logical sequence, with 91.2% expressing satisfaction with SBAR structure and 88% recommending SBAR use in other areas of the hospital. 81.4% reported quality of information received via SBAR structure was good and 56.9% of nurses identified perceived reduction in communication errors after using the SBAR structure. National Center for Cancer Care and Research Specialty Hospital (74 beds, Qatar) n=102 staff nurse surveys Level IV Panesar, Albert, Messina, & Parker, 2016 Medical record reviews of all admitted patients during the three phases of paper chart documentation, EMR, and electronic SBAR note documentation to assess presence and completion of documentation. Each study period took place 3 months after introduction of each phase. During paper chart documentation phase, 22/173 charts contained event notes vs. 28/197 during EMR phase and 34/172 during SBAR, indicating a nonstatistically significant increase in documentation during SBAR phase (p=0.07). The mean completeness of documentation during paper chart documentation phase was 2.23/4, compared to 2.57 during EMR phase, 3.24 during transition from EMR to SBAR phase, and 4/4 during SBAR phase (p<0.0001). Additionally, during SBAR-only phase documentation of notification of attending physician and bedside nurse increased to 100% (p=0.0001), indicating increased communication among resident physician, attending physician, and bedside nurse. Use of an electronic SBAR note was associated with increase in frequency of event documentation. Pre-defined fields of the SBAR note prompted residents to input appropriate information accordingly, resulting in increased completion of documentation. 12-bed pediatric ICU in University Children’s Hospital (Stony Brook, NY) n=542 chart reviews (173 paper chart phase, 197 EMR phase, 172 SBAR phase) Level IV Randmaa et al., 2016 Pre/post SBAR audio recordings and observations assessing information recall, interruptions, and disruptions in-task taken in a control and intervention group In intervention group, information recall increased from 43.4% pre-SBAR to 52.6% post-SBAR (p=0.0004), compared to control group scores of 51.3% and 52.6% respectively (p=0.725). Structure of verbal reports also improved significantly in intervention group (p=0.028), but did not in comparison group (p=0.889). Results indicated receivers of report may remember more when report is formatted to a predictable structure common to all parties. PACU in two Swedish Hospitals n=164 patient handoffs (72 personnel members including RNs, anesthesiologists, CRNAs) Level III Randmaa et al., 2014 Pre-post-SBAR comparisons of incident reports related to communication and measurements of staff perception of communication via pre/post surveys were taken in intervention and control groups In intervention group, proportion of incident reports due to communication errors decreased from 31% to 11% (p<0.0001). Staff perception of “between group communication accuracy” improved (p=0.039) as did perception of organization’s safety climate (p=0.011). Anesthetic clinics in two Swedish hospitals (type of hospital not specified) n=139 (intervention), 91 (control) Level III continued on next page September-October 2017 • Vol. 26/No. 5 301 SBAR, Communication, and Patient Safety: An Integrated Literature Review TABLE 1. (continued) Studies and Themes Author/Date Methods Results Setting/Sample LOE Raymond & Harrison, 2014 Pre/post-SBAR telephone audits to assess SBAR use and pre/post qualitative questionnaire regarding communication administered to nurses and physicians Telephone audit demonstrated SBAR use increased (no p-values reported); post-SBAR questionnaire results indicated SBAR use improved ease of communication and confidence, resulted in improved quality of patient care. 75-bed NICU, Groote Schuur Hospital (Cape Town, South Africa) n=50 telephone audits n=21 nurses, 17 physician questionnaire respondents Level IV Vardaman et al., 2012 Qualitative case studies of two hospitals implementing SBAR via semi-structured interviews, observation of nursing activities, review of documents pertaining to implementation of SBAR Four additional uses for SBAR identified beyond its use as a communication tool: schema formation (mental models impacting response to situations, mental habits), development of legitimacy (especially helpful for new nurses calling physicians), development of social capital (trust developing from individual’s relationship network), and reinforcement of dominant logics (templates to guide cognition); concluded SBAR may be valuable to professionals outside nursing (administrators, unlicensed personnel, other healthcare professionals). 339-bed acute- care suburban hospital and 140- bed suburban women’s hospital (Baptist Health Systems, MS) n=80 interviews with RNs, managers, physicians Level IV Wang et al., 2015 Pre/post SBAR workshop questionnaire assessing performance under each SBAR domain, self-perception of performance, ability in clinical practice Performance scores improved significantly (p<0.01); students’ self-perceived abilities regarding communication and SBAR also demonstrated significant improvement (p<0.01); 93.8% of students also indicated they would use SBAR in future clinical practice. Fudan University School of Nursing (Shanghai, China) n=18 master’s degree nursing students Level IV Wentworth et al., 2012 Pre/post SBAR surveys assessing ease of use, fit within workflow, timeliness of handoff, usefulness for routine patients, perceived value, ability to ask questions Proportion of staff agreeing patient handover took place between 1 and 6 minutes increased post-SBAR (no p-value reported); nurses also agreed SBAR tool was reliable standard method for handing off patients without interrupting workflow (no p-values reported). 33-bed progressive care unit, 6-room electrophysiology laboratory, 6-room cardiac catheterization laboratory n=51 nurse surveys Level IV CRNA = certified registered nurse anesthetist, EMR = electronic medical record, ICU = intensive care unit, IDR = interdisciplinary rounding, LOE = level of evidence, NICU = neonatal intensive care unit, NP = nurse practitioner, PACU = postanesthesia care unit, RCT = randomized controlled trial, RN = registered nurse, SAE = significant adverse event, SBAR-PETS = situation-background- assessment-recommendation pre-handover equipment handover timeout sign-out Note: Each article graded using Melnyk’s hierarchy of evidence (Melnyk & Fineout-Overholt, 2015) September-October 2017 • Vol. 26/No. 5302 Use of SBAR Creates a Common Language for Communication of Key Patient Care Information. When used to guide information exchange between nurses and physi- cians, SBAR bridges the communica- tion gap that may exist between the two professions due to different communication styles (Panesar, Albert, Messina, & Parker, 2016; Randmaa, Martensson, Swenne, & Engström, 2014). In addition, use of the SBAR tool temporarily flattens the hierarchy perceived in some healthcare settings. This creates more effective channels of commu- nication be tween providers (De Meester, Verspuy, Monsieurs, & Van Bogaert, 2013; Vardaman et al., 2012). Historically, nurses and physi- cians have been taught to communi- cate using styles suited to the needs and thought processes of their respective professions (Raymond & Harrison, 2014). Nurses as direct caregivers tend to communicate using a subjective, narrative style that reflects the continuous flow of information received in the perform- ance of their daily responsibilities (Westwood et al., 2012). In contrast, physicians tend to communicate via an objective, headline approach that echoes the action-oriented method of traditional medical education in which expertise of the diagnosis and treatment of the disease demands quick action based on the objectivity of current evidence (Westwood et al., 2012). Professionals’ use of different styles can result in miscommunica- tion or omission of key patient care information that may jeopardize patient safety. The SBAR framework combines the communication styles of nurses and physicians, establish- ing a method for handoff reports that promotes effective information- al ex change between the members of the two professions (Panesar et al., 2016; Raymond & Harrison, 2014). Results of a correlational descrip- tive study (Panesar et al., 2016) indicated use of SBAR by nurses and physicians creates a shared mental model between the two professions which leads to enhanced communi- cation. In addition, a foundational case study found the recommenda- tion portion of the SBAR tool improved the situational awareness of physicians by allowing them to view the patient through the eyes of the direct caregiver (Haig, Sutton, & Whittington, 2006). This further enhanced patient safety and com- munication between providers. These findings were confirmed by another correlational descriptive study in which use of the SBAR tool to guide information exchange resulted in emphasis on situational facts over ancillary information and improvement of overall hand- off communication (McCrory, Aboum atar, Custer, Yang, & Hunt, 2012). The integration of profes- sional communication styles in the SBAR tool contributes to a more holistic pro cess for communication, adding standardization to nurses’ individualized assessment report and increasing the situational awareness of physicians (Haig et al., 2006; McCrory et al., 2012). As a communication structure used by all healthcare professions, the SBAR communication tool also serves to eliminate temporarily the perceived hierarchies of the health- care system (De Meester et al., 2013; Vardaman et al., 2012). With con- sistent use in an organization, the SBAR tool prevents the context of handoff exchanges from being one in which the speaker feels pressured to edit the content of a report due to the perceived hierarchical status of the receiver. Using the SBAR tool, nurses in one correlational descrip- tive study (De Meester et al., 2013) became more willing to contact the attending physician earlier regard- ing a change in patient condition; they indicated use of the SBAR tool eliminated their fear of “looking stupid” (p. 1195) when speaking to a physician with higher perceived status. This response on the part of nurses subsequently led to in - creased patient transfers to inten- sive care units (p=0.001) with a cor- responding decrease in the number of unexpected patient deaths (p<0.001). Similarly, qualitative case studies of SBAR implementation (Vardaman et al., 2012) found nurs- es were more comfortable commu- nicating with physicians as a result of developing legitimacy when using the SBAR tool. However, simply providing SBAR forms does not ensure communica- tion of pertinent information. A randomized controlled trial (Joffe et al., 2013) found situation cues remained consistent in verbal reports between disciplines (p=0.6) while fewer background cues were reported when the SBAR tool was used (p=0.8). While these results were not statistically significant, they were consistent with previous findings that use of SBAR leads to an emphasis on current situational information with less focus on background (McCrory et al., 2012). Use of SBAR Increases Confidence of Speaker and Receiver of Handoff Report. Standardizing the format elimi- nates the question of how to con- duct a handoff report by giving the speaker an established method for communication, thus improving his or her confidence in the ability to provide an effective report (Ray - mond & Harrison, 2014; Wang, Liang, Blazeck, & Greene, 2015). In two correlational descriptive studies assessing the consistency of handoff reports between nurses using SBAR, authors concluded handoffs for- matted according to the SBAR tem- plate were more consistent (Cor - nell, Townsend-Gervis, Yates, & Vardaman, 2014; Wentworth et al., 2012). Because the order of the report is uniform regardless of the profession, experience, or position of the users, use of the SBAR tem- plate enables the speaker and the receiver to focus on the information being exchanged (Fay-Hillier, Reg - an, & Gallagher Gordon, 2012; Randmaa, Swenne, Martensson, Högberg, & Engström, 2016). Consistent use of SBAR also aids in identification and correction of omitted information, subsequently improving the receiver’s confidence in the information contained in the handoff report (Blom, Petersson, Hagell, & Westergren, 2015). In a quasi-experimental study by Randmaa and colleagues (2014), use of the SBAR framework by nurses and physicians decreased the receiv- er’s impression of needing to consult the medical record to verify informa- tion communicated in the handoff report; the receiver felt more confi- dent in the information provided. In September-October 2017 • Vol. 26/No. 5 303 a pre/post survey and observational study, Martin and Ciurzynski (2015) found use of SBAR by nurses and nurse practitioners in a pediatric emergency department resulted in more concise reports due to the anticipated nature of SBAR. Overall, implementation of SBAR leads to a more concise report in which omis- sions are identified more easily and information is anticipated readily (Blom et al., 2015; Martin & Ciur - zynski, 2015). Use of SBAR Improves Efficiency, Efficacy, and Accuracy of Handoff Report. Use of the SBAR communication template gives the handoff report a standardized format that becomes habitual for users, decreasing the time on non-pertinent tasks during a report and increasing its efficacy (Cornell et al., 2014; Wentworth et al., 2012). Performing a task the same way every time facilitates improved proficiency for the user. In a correlational descriptive study, implementation of the SBAR tem- plate for use during nurse-to-nurse shift handoff and interdisciplinary rounds resulted in increased time spent on shift report tasks, from 14.3 minutes pre-SBAR to 21.5 min- utes (paper) and 25.4 minutes (elec- tronic) post-SBAR (p<0.01). Simul - taneously, total time to complete the shift report decreased from an average of 53 minutes pre-SBAR to 38.1 post-SBAR (p<0.01) (Cornell et al., 2014). Authors also concluded consistent use of SBAR during inter- disciplinary rounding and nurses’ shift handoff report resulted in more focused patient reviews and shift reports, with an increased vol- ume of information exchanged and reduced time spent on non-perti- nent information. While decreasing the time for handoff report was not the primary goal, increasing report efficiency and reduced time spent on extraneous and unnecessary patient information allowed health- care professionals to dedicate more time to activities related directly to patient care. Consistent use of the SBAR tech- nique also improved the accuracy, clarity, and efficacy of information exchanged during report (Blom et al., 2015; Randmaa et al., 2014). The simplicity and consistency of the SBAR communication tool facilitates professionals’ ability to differentiate the information needed for safe patient care and then convey the information correctly (Randmaa et al., 2014). In a survey study, use of the SBAR tool was reported by nurses to improve the sufficiency (p<0.0001), clarity (p<0.0001), and accuracy (p<0.001) of the content in the handoff report (Fabila et al., 2016). Use of the SBAR tool during handoffs in a quasi-experimental study decreased the proportion of incident reports related to misunder- standing, misinterpretation, or omis- sion of information from 31% to 11% (Randmaa et al., 2014). Likewise, another correlational de - scriptive study showed SBAR use resulted in improved clarity in the delivery of key information (p=0.002) (Mitchell et al., 2013). By providing a standardized expecta- tion for the structure of the handoff report, use of the SBAR tool guides the speaker in giving a focused, rele- vant, factually correct report. Use of SBAR Improves the Perception of Effective Communication and Is Well- Received Among Healthcare Staff. The SBAR framework is consid- ered by nurses and physicians to be an effective method for organizing the handoff report. In a study using pre/post SBAR implementation ques tionnaires to evaluate health- care providers’ perceptions of com- munication, Blom and co-authors (2015) concluded introduction of the SBAR tool resulted in improved perceptions of communication in nurse-to-nurse and nurse-to-physi- cian scenarios. Implementation of an SBAR document (SBAR-PETS) for handoff between anesthetists and non-anesthetist personnel in anoth- er study also resulted in an increase in the proportion of survey respon- dents indicating exchanged infor- mation was frequently or always suf- ficient (p<0.0001) (Fabila et al., 2016). Additionally, Nagammal, Nashwan, Nair, and Susmitha (2017) found 95.1% of nurses con- sidered SBAR to follow a logical order, with 91.2% expressing satis- faction with the tool and 88% rec- ommending its use for handoff. Authors of other quasi-experimental studies also identified the common perception among healthcare staff that use of the SBAR tool during handoff increases communication and collaboration (De Meester et al., 2013; Martin & Ciurzynski, 2015). These findings are clinically signifi- cant …

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