Site menu:

Improving Patient Satisfaction with Nurse Knowledge Exchange

Literature Review (Preliminary)


Excellent communication among caregivers is essential for maintaining quality patient care; this is especially true when it comes to transitioning patient care between shifts or between departments. Barriers to effective handouts exist in many hospitals. These include, among others, a healthcare system that focuses on individual instead of team performance, lack of engagement of patients and their families with the staff, environmental problems such as noise and interruptions, language barriers, lack of time, and more. Handoffs are so important that communications problems are rated as the most common cause of sentinel events in U.S. hospitals . This is not just a problem in the U.S.; the National Health System in Scotland created a specific program to control the flow of knowledge among healthcare practitioners.

The Problem

Handoffs are of sufficient concern that the Joint Commission has targeted them as an area of concern. Emerman and Rosenthal (2008) note that one key element of the Joint Commission’s concern is to improve National Patient Safety Goals (NPSGs), particularly those that are difficult to monitor. Specifically, Emerman and Rosenthal note that the Joint Commission wanted to implement some form of standardized handoff communications that is done in a manner that enabled the ability to ask questions of the departing staff. One issue is that research evidence is not always clearly linked to proposed or attempted policy or procedural changes; this shows up when those who define new procedures are asked about the research evidence that supports those changes.

Evidence-based handoffs have been provided by Caple and Pravikoff (2011), who document the importance of providing efficient, clear, and consistent handoff data whether transitioning a patient from shift to shift or from department to department.

Specific departments may have unique problems in doing handoffs. One particular area of concern for handoffs occurs when patients transition from ED to inpatient wards. This can be particularly prevalent when the patient has been “boarded” or retained physically in the ED although officially admitted to the hospital (Dorsey and Litzenburg, 2010). Interruptions are legion in hospital environments. For example, one development project noted that one nurse doing one medication pass to give medication to one patient was interrupted seventeen times (McCreary, 2010). An additional issue arises in mental health nurses, where problems have been documented in which the least powerful nurses’ voices were not heard during handoff situations (Buus, 2006).

Potential Solutions

A variety of solutions have been proposed to improve patient handoffs. In 2007 an Illinois hospital developed a specific protocol for patient handoffs that cut the time required from almost 9 minutes per patient to 4 minutes, yet included more critical information (White and Hall, 2008). For pediatric cases, a 30-second head-to-toe update was developed as part of the University of Florida to teach pediatric nurses how to transfer knowledge to incoming shift personnel an in the process reduced student errors and standardized the routine for shift changes (Popovich, 2011). Joshi and Best (2010) identify six specific process improvements to reduce healthcare mistakes, including a key improvement for greater handoff reliability and clarity.

Using a standardized handoff system can improve effectiveness when framed through seven mechanisms, including using the most prevalent intervention in the literature, highlighting data that varies from expected values, making the thought process transparent via conversation, transferring both responsibility and authority, providing perspectives from multiple people, noting how transferring care can change the team process, and establishing a recognized cultural norm within the healthcare environment (Healthcare Benchmarks, 2010). An additional approach was developed by a midwest hospital system which focused on providing an interdepartmental communication capability during handoffs to ensure that an accurate portrayal of the patient’s condition was conveyed to the incoming healthcare team (Brown, 2007).


Kaiser Permanente has focused on addressing the issue of poor communications between staff in a hospital setting and has developed a program called NKEplus or Nurse Knowledge Exchange plus. This program is now available for non-Kaiser hospitals for implementation and has provided a variety of tools to educate and implement their program (Innovation Consultancy, 2010; Innovation Consultancy, 2011). The idea behind this was to move the shift change knowledge transfer to the patient’s bedside which accomplished two key elements: it assured that incoming nurses were not delayed in making contact with the patients, and it engaged the patient in the knowledge transfer process (McCreary, 2010).

NKE and NKEplus have been implemented in hospitals to enable better patient handoffs. The program is based on several principles including making the process patient centered so it is warm and friendly for patient and family; doing handoffs verbally and face-to-face in front of the patient to engage the patient; making the handoffs team-centered across shifts; making the process efficient so nurses have no waiting time to discover their assignments; and keeping the process focused as nurses prepare and receive only their own patients (Fahey and Schilling, 2007).


Transferring care from shift to shift or from department to department is one area of healthcare that is open to many areas. The Joint Commission has identified such patient handoffs as an area of concern to increase patient safety. While a number of solutions to this problem have been identified, one has proved to be of particular interest, which is the Kaiser Permanente NKEplus system. It is this system of exchanging knowledge among nurses that is the subject of this report.