Consegna infermieristica con metodo SBAR: uno studio quasi-sperimentale
10.54103/dn/17691
INTRODUZIONE:Il passaggio delle consegne è un aspetto cruciale per la sicurezza del paziente e per la continuità delle cure. Molti fattori possono influenzare la qualità delle informazioni trasmesse rendendo il processo inefficace o addirittura dannoso se le informazioni sono incomplete o omesse.
OBIETTIVI:L'obiettivo primario dello studio era descrivere i cambiamenti nella qualità della consegna infermieristica dopo l'introduzione del metodo Situation, Background, Assestment and Raccomandation (SBAR).
Gli obiettivi secondari erano la descrizione dei cambiamenti nel numero di interruzioni e dei cambiamenti nelle abilità di comunicazione nell'handover infermieristico.
MATERIALI E METODI:Uno studio quasi sperimentale, monocentrico con disegno pre/post test è stato implementato con un campionamento di convenienza.
RISULTATI:198 infermieri hanno partecipato allo studio e sono stati analizzati 208 handover infermieristici.
Dopo l'introduzione del metodo SBAR c'è stato un miglioramento significativo della qualità dei passaggi di consegne, una riduzione del numero di interruzioni e un aumento delle capacità di comunicazione.
CONCLUSIONI:Il metodo SBAR migliora la qualità delle consegne infermieristiche riducendo il numero di interruzioni e migliorando le capacità di comunicazione.
L'introduzione del metodo di consegna SBAR contribuisce alla qualità ed alla sicurezza della trasmissione delle informazioni.
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Cinzia Garofalo 
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Dissertation Nursing
consegne infermieristiche
Consegna infermieristica con metodo SBAR: uno studio quasi-sperimentale
Text.Serial.Journal
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Cinzia Garofalo 
2022/07/29
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Nursing Director - UOC Emergency and Urgency Tuscany South East 
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consegne infermieristiche
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Smeulers M, Vermeulen H. Best of both worlds: combining evidence with local context to develop a nursing shift handover blueprint. Int J Qual Health Care J Int Soc Qual Health Care. 2016 Dec 1;28(6):749–57.
Nurse Handover with SBAR method: a quasi-experimental study
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                                                                                                                             DOI: 10.54103/dn/17691




               DISSERTATION NURSING
               Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing
QUASI-EXPERIMENTAL STUDY

                     Nurse Handover with SBAR method:
                         a quasi-experimental study.
                        1
Maria Cristina Monti      , Stefano Maiandi2, Lucia Rossi1, Miriam Villani1, Cinzia Garofalo3
1 HealthcareProfessions Department – ASST di Lodi
2 Development  and Research - Healthcare Professions Department – ASST di Lodi
3 Nursing Director - UOC Emergency and Urgency Tuscany South East




Findings:                                              ABSTRACT
Implementing a standardized handover                   BACKGROUND:
framework such as the SBAR method allows               Handover is a crucial aspect for patient safety and continuity of care. Many
for concise and comprehensive information
handoffs and allows early interception of
                                                       factors can affect the quality of the information transmitted and handover
clinical instability.                                  may be ineffective or even harmful if the information is incomplete or
                                                       omitted.

                                                       AIM:
Aknowledgment:                                         The primary objective of the study was to describe the changes in handover
                                                       quality after introduction of the Situation, Background, Assestment and
A special thanks to Franca Guerrini, Maria             Raccomandation (SBAR) method.
Merli, all the nursing coordinators and nurses         Secondary objectives were to describe changes in the number of
in pilot wards.
                                                       interruptions and changes in communication skills in nursing handover.

                                                       METHODS:
                                                       A quasi-experimental, monocentric study with pre/post test design was
                                                       implemented in a sample of convenience.

                                                       RESULTS:
                                                       198 nurses participated in the study and 208 nursing handovers were
                                                       analyzed. After the introduction of the SBAR method there has been a
                                                       significant improvement in the quality of handovers, a reduction in the
                                                       number of interruptions and an increase in communication skills.

                                                       CONCLUSION:
                                                       SBAR method demonstrably improves the quality of nursing handovers,
                                                       reducing the number of interruptions and enhancing communication skills.
                                                       The introduction of the SBAR delivery method improves the quality and
                                                       safety of information transmission.



                             KEYWORDS: Continuity of care, patient handoff, communication, nurse handover.


       Corresponding author:                                                  3
                                                                                                                  Submission received: 08/04/2022
       Stefano Maiandi: stefano.maiandi@asst-lodi.it
                                                                                                           End of Peer Review process: 17/05/2022
       ASST di Lodi
                                                                                                                            Accepted: 18/05/2022
       Piazza Ospitale 10, 26900 Lodi - Italy            Via Festa del Perdono 7, 20122 Milan, Italy
                                                                                         This work is licensed under a Creative Commons
         Dissertation Nursing 1 (29/07/2022)                                             Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                              DOI: 10.54103/dn/17691




               DISSERTATION NURSING
               Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing

Studio Quasi-sperimentale

                Consegna Infermieristica con metodo SBAR:
                      uno studio quasi-sperimentale
                         1
Maria Cristina Monti       , Stefano Maiandi2, Lucia Rossi1, Miriam Villani1, Cinzia Garofalo3
1 HealthcareProfessions Department – ASST di Lodi
2 Development  and Research - Healthcare Professions Department – ASST di Lodi
3 Nursing Director - UOC Emergency and Urgency Tuscany South East




Riscontri:                                              ABSTRACT
L'implementazione di una metodologia                    INTRODUZIONE:
standardizzata per il passaggio di consegne,            Il passaggio delle consegne è un aspetto cruciale per la sicurezza del paziente e
come il metodo SBAR, consente di fornire
informazioni concise e complete e di
                                                        per la continuità delle cure. Molti fattori possono influenzare la qualità delle
identificare precocemente l'instabilità clinica.        informazioni trasmesse rendendo il processo inefficace o addirittura dannoso
                                                        se le informazioni sono incomplete o omesse.

Ringraziamenti:                                         OBIETTIVI:
                                                        L'obiettivo primario dello studio era descrivere i cambiamenti nella qualità
Un ringraziamento speciale a Franca                     della consegna infermieristica dopo l'introduzione del metodo Situation,
Guerrini, Maria Merli, a tutti i coordinatori           Background, Assestment and Raccomandation (SBAR). Gli obiettivi secondari
infermieristici ed a tutti gli infermieri nei           erano la descrizione dei cambiamenti nel numero di interruzioni e dei
reparti pilota.                                         cambiamenti nelle abilità di comunicazione nell'handover infermieristico.

                                                        MATERIALI E METODI:
                                                        Uno studio quasi sperimentale, monocentrico con disegno pre/post test è
                                                        stato implementato con un campionamento di convenienza.

                                                        RISULTATI:
                                                        198 infermieri hanno partecipato allo studio e sono stati analizzati 208
                                                        handover infermieristici.
                                                        Dopo l'introduzione del metodo SBAR c'è stato un miglioramento
                                                        significativo della qualità dei passaggi di consegne, una riduzione del numero
                                                        di interruzioni e un aumento delle capacità di comunicazione.

                                                        CONCLUSIONI:
                                                        Il metodo SBAR migliora la qualità delle consegne infermieristiche riducendo
                                                        il numero di interruzioni e migliorando le capacità di comunicazione.
                                                        L'introduzione del metodo di consegna SBAR contribuisce alla qualità ed alla
                                                        sicurezza della trasmissione delle informazioni.



                  KEYWORDS: Continuità dell'assistenza, passaggio di consegne, comunicazione, consegne infermieristiche

        Corresponding author:                                                  4
                                                                                                                   Submission received: 08/04/2022
        Stefano Maiandi: stefano.maiandi@asst-lodi.it
                                                                                                            End of Peer Review process: 17/05/2022
        ASST di Lodi
                                                                                                                             Accepted: 18/05/2022
        Piazza Ospitale 10, 26900 Lodi - Italy            Via Festa del Perdono 7, 20122 Milan, Italy
                                                                                          This work is licensed under a Creative Commons
         Dissertation Nursing 1 (29/07/2022)                                              Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                          DOI: 10.54103/dn/17691




          DISSERTATION NURSING
           Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



BACKGROUND                                                                       drawing out the time required for both written and
Nursing delivery in healthcare is recognized as an                               verbal delivery and without reducing the time spent
important factor in improving the safety of patients                             with the patient and his family (7,10).
and the quality of care to ensure continuity of care                             The primary objective of the study is to describe the
(1).                                                                             changes in handover quality after the introduction of
Different types of nursing handover are described in                             the SBAR method in ASST in Lodi, Italy.
the literature but the focus on content, clinical history                        Secondary objectives of the study are to describe
and planning is higher during verbal delivery (2).                               changes in the number of interruptions and changes
Verbal delivery has many positive aspects such as                                in communication skills in nursing handover after the
sharing information, continuity of care, protection of                           introduction of the SBAR method.
the     person      assisted,    cooperative    learning,
development of collaboration within the group,
support for team members and the expression of                                   METHODS
knowledge and experience with consequent                                         A quasi-experimental monocentric pre/post test
continuous training among colleagues (1).                                        design study has been carried out.
However, nurses handover may be ineffective or
even harmful if the information is incomplete or                                 A convenience sample of 198 nurses from eight Units
omitted (3–7).                                                                   of the ASST Lodi was identified from Internal
An effective nursing handover should be accurate,                                Medicine Unit, Infectious Disease Unit, General
complete, timely, unambiguous and easily understood                              Surgery, Specialist Surgery, Emergency Room,
by the receiver (8–11).                                                          Intensive Care Unit, Pediatrics, Psychiatric Unit.
Changing handover method is complicated and
requires effective implementation strategies and                                 Inclusion and exclusion criteria
training reinforcement (8,12).                                                        Inclusion: nurses from the selected
The literature suggests the use of standardized                                          departments who have successfully completed
nursing delivery models such as the SBAR model                                           the period of tutoring
(5,7–9,13,14).                                                                        Exclusion: nurses who provide delivery not
In 2007 the Joint Commission International (JCI) and                                     in their own ward.
the World Health Organization (WHO) suggested the                                The observations of the nursing handovers, before
implementation of a structured communicative                                     and after the implementation of the SBAR
delivery approach using the SBAR (Situation,                                     methodology, were carried out by specifically trained
Background,         Assessment,       Recommendation)                            nursing evaluators using the Handoff Check tool
technique as a precise and versatile handover tool                               validated in Italian language (13).
(8,9).                                                                           The Handoff check measures the quality of
SBAR model can be used in all clinical settings,                                 communications in delivery and consists of 6 survey
especially in emergency settings, creating a structured                          items: context, level of interruptions, handover
language that increases the effectiveness, efficiency                            organization, communication skills, content, clinical
and accuracy of handovers and improves care                                      judgement as problem solving skills and
outcomes (4,6,7,10,15–20).                                                       human/professional qualities.
The use of the SBAR method reduces the number of                                 The last two evaluation areas represent an overall
preventable      adverse      events   and     improves                          judgement of the observation of the handover
communication between team members without
      Corresponding author:                                                5
                                                                                                               Submission received: 08/04/2022
      Stefano Maiandi: stefano.maiandi@asst-lodi.it
                                                                                                        End of Peer Review process: 17/05/2022
      ASST di Lodi
                                                                                                                         Accepted: 18/05/2022
      Piazza Ospitale 10, 26900 Lodi - Italy          Via Festa del Perdono 7, 20122 Milan, Italy
                                                                                      This work is licensed under a Creative Commons
       Dissertation Nursing 1 (29/07/2022)                                            Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                            DOI: 10.54103/dn/17691




          DISSERTATION NURSING
           Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



process and the level of agreement between evaluator                             Given this variability, the median number of patients
and observed.                                                                    described in each delivery is 10, IQR [4;14], range
To avoid the Hawthorne effect, no information on                                 [1;22].
the study objectives was provided to the nurses                                  The median duration of deliveries was 15 minutes,
observed and the evaluators completed the Handoff                                IQR [11;22], range [4;40]; this data is linked to the
check scale at the end of the observation.                                       number of hand-over to deliver, which exponentially
                                                                                 increases the time required (Figure 1).
Data analysis
For management of data of each domain of the                                       50
Handoff check scale, position and dispersion
                                                                                   40
measurements (Median, Range and Interquartile
Range) have been obtained.                                                         30

χ2 test was calculated to highlight differences in the                             20
proportions between the two groups (pre and post
                                                                                   10
test) based on the frequency of items evaluated as                                                                                      y = 7.3177e0.0749x
negative (values between 1 and 3 on the Likert scale)                               0
                                                                                        0              5            10             15              20        25
and positive (values between 4 and 9 on the Likert
scale); a p-value < 0.05 was considered significant.                               Figure 1 - Delivery time trend as a function of the number of
                                                                                                              patients
Ethical considerations
All participants agreed and gave their written
                                                                                 In the pre-implementation phase, 77 handovers were
informed consent. Since the study did not concern
                                                                                 collected between the morning and afternoon shifts,
the patients, the convening of an Ethic Committee
                                                                                 66 between afternoon and night, 65 between night
was not deemed necessary, in compliance with local
                                                                                 and morning, while in the post-implementation phase,
regulation.
                                                                                 77 deliveries were collected between the morning and
                                                                                 afternoon shifts, 65 between afternoon and night, 66
                                                                                 between night and morning.
RESULTS
                                                                                 Pre-implementation data are summarized in Table 1
198 nurses participated in the study; 5 nurses had less
                                                                                 and show a partially homogeneous situation with
than one year's experience, 21 from 1-2 years, 53
                                                                                 lower scores in surgical wards. The item "context" is
from 3-5 years, 119 from over 5 years.
                                                                                 the one that shows the lowest scores among those
In addition, 11 nurses had been working in the survey
                                                                                 investigated while very positive scores were recorded
ward for less than one year, 56 for 1-2 years, 57 for 3-
                                                                                 in Intensive Care Unit and Infectious Diseases Unit.
5 years, 74 for more than 5 years.
                                                                                 All the items evaluated in observation of the post-
A total of 208 handover observation forms were
                                                                                 implementation delivery process, summarized in
completed; 104 completed in the pre-implementation
                                                                                 Table 2, show a clear improvement with pilot
phase and 104 in the post-implementation phase.
                                                                                 departments reaching values of 7-8 on the Likert
The median number of patients in the sample,
                                                                                 scale.
considering all departments, was 14, IQR=[10;23],
                                                                                 The global assessment of the evaluator/observer on
ranging from 2 (Emergency Room) to 42 (Internal
                                                                                 the handover delivered achieved very high scores with
Medicine Unit).

      Corresponding author:                                                6
                                                                                                                  Submission received: 08/04/2022
      Stefano Maiandi: stefano.maiandi@asst-lodi.it
                                                                                                           End of Peer Review process: 17/05/2022
      ASST di Lodi
                                                                                                                            Accepted: 18/05/2022
      Piazza Ospitale 10, 26900 Lodi - Italy          Via Festa del Perdono 7, 20122 Milan, Italy
                                                                                        This work is licensed under a Creative Commons
       Dissertation Nursing 1 (29/07/2022)                                              Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                          DOI: 10.54103/dn/17691




          DISSERTATION NURSING
           Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



a good level of agreement with the nurses involved in                            Distractions caused by staff, sound of patient call
the handover process.                                                            systems and sounds of monitors have shown to
In the surgical wards there was a clear improvement                              negatively affect the reception of information in all
in all items investigated, mainly in the reduction of                            nursing handovers.
interruptions, organization of handovers and in the                              These interruptions lead to lack of concentration and
implementation of communication and clinical skills;                             loss of up-to-date and complete information on the
there was also an improvement in the clinical                                    clinical course of the patient.
information content.                                                             To resolve the issue, a professional not involved in
In the Infectious Diseases Unit there was no                                     handover was identified to answer patient call systems
improvement after implementation; in the Internal                                and telephone calls and to deal with interruptions by
Medicine Unit there was a minor improvement in the                               other professionals, patients and caregivers.
containment of interruptions and in communication                                For surgical wards, it was agreed with the recovery
skills.                                                                          room of the operating theatres that patients should
In the Pediatrics Unit, a fair improvement (on average                           not be discharged to the wards during the handover
one point on Likert scale) was found, equally                                    period.
distributed over all items investigated; a more                                  The same system was implemented in the emergency
significant improvement on all items investigated was                            room, asking the staff not to transfer new admissions
shown in the Emergency Room (average of two                                      during handovers.
points on Likert scale), with a clear improvement in                             As a result of the above measures, five of the eight
the containment of interruptions in the handover                                 pilot units have achieved significant results in terms
process.                                                                         of the effectiveness of the barrier systems, recording
In the psychiatric unit the improvement in all the                               excellent post-implementation evaluations on the
items evaluated was noted, except for the                                        control of interruptions and disruptions in the
organization of the delivery, confirmed at optimal                               handover process.
levels but with a slight deterioration in the control of                         Psychiatry, where there is a modest worsening, goes
interruptions in contrast to the other pilot wards.                              against the trend.
The analysis of the handover content item showed a                               The analysis of the results confirmed the effectiveness
significant improvement in the pilot units; general                              of the strategy to contain distractions (3,21).
surgery that started from insufficient values also                               In line with the current literature (10,16,20), a lack of
showed a marked improvement.                                                     adequate communication skills among nursing staff
The improvement of the items investigated in the                                 was also confirmed by the results of this study,
pilot units shows a statistical significance in context,                         particularly for specialist surgery and Emergency
communication skills and human and professional                                  Room.
qualities and is summarized in Table 3.                                          After appropriate training on communication
                                                                                 processes, the results showed a significant
                                                                                 improvement; two wards (specialist surgery and
DISCUSSION                                                                       intensive care unit) reached the maximum result.
As per the existing literature (7,10), the results of this                       The results confirm the data in the literature on the
study confirm the potential of the SBAR system as an                             need to adopt effective communication mechanisms
optimal handover tool.                                                           and the need for expertise in giving, receiving,
                                                                                 verifying information and making summaries

      Corresponding author:                                                7
                                                                                                               Submission received: 08/04/2022
      Stefano Maiandi: stefano.maiandi@asst-lodi.it
                                                                                                        End of Peer Review process: 17/05/2022
      ASST di Lodi
                                                                                                                         Accepted: 18/05/2022
      Piazza Ospitale 10, 26900 Lodi - Italy          Via Festa del Perdono 7, 20122 Milan, Italy
                                                                                      This work is licensed under a Creative Commons
       Dissertation Nursing 1 (29/07/2022)                                            Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                         DOI: 10.54103/dn/17691




         DISSERTATION NURSING
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



(7,10,11,22). The overall evaluation of the handover                                   Hautz WE, Stock S. Impact of the
and the degree of agreement between participants                                       communication and patient hand-off tool SBAR
both show an improvement in the quality of                                             on patient safety: a systematic review. BMJ
                                                                                       Open. 2018;8(8):e022202.
information transmission after the implementation of
the SBAR method.                                                                7.     Starmer AJ, Spector ND, Srivastava R, West
                                                                                       DC, Rosenbluth G, Allen AD, et al. Changes in
                                                                                       Medical Errors after Implementation of a
CONCLUSION                                                                             Handoff Program. N Engl J Med.
Improving the communication process and reducing                                       2014;371(19):1803–12.
interruptions in nursing handover are a priority in                             8.     Merten H, van Galen LS, Wagner C. Safe
terms of impact on the quality of care.                                                handover. BMJ. 2017;359:j4328.
The introduction of the SBAR delivery method
improves the safety of transmitted information by                               9.     Pucher PH, Johnston MJ, Aggarwal R, Arora S,
decreasing the number of interruptions and increasing                                  Darzi A. Effectiveness of interventions to
nurses' specific skills in transmitting medical                                        improve patient handover in surgery: A
                                                                                       systematic review. Surgery. 2015 Jul;158(1):85–
information.                                                                           95.

                                                                                10. Randmaa M, Mårtensson G, Leo Swenne C,
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     Corresponding author:                                                8
                                                                                                              Submission received: 08/04/2022
     Stefano Maiandi: stefano.maiandi@asst-lodi.it
                                                                                                       End of Peer Review process: 17/05/2022
     ASST di Lodi
                                                                                                                        Accepted: 18/05/2022
     Piazza Ospitale 10, 26900 Lodi - Italy          Via Festa del Perdono 7, 20122 Milan, Italy
                                                                                     This work is licensed under a Creative Commons
       Dissertation Nursing 1 (29/07/2022)                                           Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                         DOI: 10.54103/dn/17691




         DISSERTATION NURSING
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



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     Corresponding author:                                                9
                                                                                                              Submission received: 08/04/2022
     Stefano Maiandi: stefano.maiandi@asst-lodi.it
                                                                                                       End of Peer Review process: 17/05/2022
     ASST di Lodi
                                                                                                                        Accepted: 18/05/2022
     Piazza Ospitale 10, 26900 Lodi - Italy          Via Festa del Perdono 7, 20122 Milan, Italy
                                                                                     This work is licensed under a Creative Commons
       Dissertation Nursing 1 (29/07/2022)                                           Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                DISSERTATION NURSING
                            Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing




APPENDICES:

Table 1 - Evaluation item Handoff CEX pre-implementation of SBAR model

                                                                                             INTERNAL
ITEM HANDOFF               GENERAL             SPECIALIST            INFECTIOUS                                                               EMERGENCY                 PSYCHIATRIC            INTENSIVE
                                                                                             MEDICINE            PAEDIATRICS
                           SURGERY              SURGERY             DISEASE UNIT                                                                ROOM                       UNIT                CARE UNIT
                                                                                               UNIT
                         Me[IQR]   Range      Me[IQR]     Range     Me[IQR]      Range     Me[IQR]     Range     Me[IQR]           Range       Me[IQR]       Range       Me[IQR]       Range   Me[IQR]   Range
CONTEXT                     5        1-9         5         2-9         8         3-9         6         1-9             7           5-8            4           1-9          7.5         3-9       5       1-9
ORGANISATION                7        3-9         6         3-9         8         3-9         8         5-9             7           5-9            7           4-9           8          4-9       8       4-9
COMMUNICATION
SKILLS                      7        4-9         6         3-8         8         3-9        7.5        5-9             7           5-9            7           4-9           7          5-9       8       4-9
CONTENT                     5        1-7         7         4-9         8         3-9         8         5-9             7           6-8            7           6-8           7          5-8       8       4-9
CLINICAL JUDGEMENT          7        2-9         7         3-9         8         6-9         8         5-9             7           5-9            7           4-9           7          5-9       8       5-9
HUMAN/PROFESSIONAL
QUALITIES                   7        3-9         6         2-9         8         3-9         8         6-9             7           6-8            7           3-9           7          5-9       8       6-9
GLOBAL JUDGEMENT           6.5       3-9         6         3-9         8         5-9         8         6-9             7           6-8           6.5          4-8           7          5-9      7.5      5-9
AGREEMENT                   6        4-8         7         5-9         8         6-9         8         6-8             7           6-8            7           5-8           7          6-8       8       6-9




                            Corrisponding author:                                            10                                         Submission received: 08/04/2022
                            Stefano Maiandi: stefano.maiani@asst-lodi.it                                                         End of Peer Review process: 17/05/2022
                            ASST di Lodi                                                                                                          Accepted: 18/05/2022
                            Piazza Ospitale 10, 26900 Lodi - Italy       Via Festa del Perdono 7, 20122 Milan, Italy
                                                                                                                           This work is licensed under a Creative Commons
                             Dissertation Nursing 1 (29/07/2022)                                                           Attribution-NonCommercial-NoDerivatives 4.0 international
                                       DISSERTATION NURSING
                                     Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing


 Table 2 - Evaluation item Handoff CEX post-implementation of SBAR model

                                                                                                        INTERNAL
ITEM HANDOFF              GENERAL                   SPECIALIST               INFECTIOUS                                                                EMERGENCY                  PSYCHIATRIC                   INTENSIVE
                                                                                                        MEDICINE                PAEDIATRICS
                          SURGERY                    SURGERY                DISEASE UNIT                                                                 ROOM                        UNIT                       CARE UNIT
                                                                                                          UNIT
                       Me[IQR]        Range        Me[IQR]        Range     Me[IQR]           Range   Me[IQR]      Range    Me[IQR]         Range       Me[IQR]       Range        Me[IQR]        Range         Me[IQR]         Range
CONTEXT                   7             4-9           9           8-9           8             5-9      6.5         5-9           8          7-9            9           8-9              7         6-9             9             9-9
ORGANISATION              8             5-9           9           9-9           8             5-9       8          5-9           8          8-9            9           8-9              8         7-9             9             9-9
COMMUNICATION
SKILLS                    8             6-9           9           8-9           8             7-9       8          6-9           8          7-9            9           8-9              8         7-9             9             9-9
CONTENT                   7             5-8           8           8-9           8             7-9       8          5-9           8          7-9            9           8-9              8         8-9             9             9-9
CLINICAL
JUDGEMENT                 9             7-9           9           8-9           8             5-9       8          6-9           8          7-9            9           8-9              8         7-9             9             8-9
HUMAN/PROFESSIO
NAL QUALITIES             8             7-9           9           8-9           8             6-9       8          7-9           8          8-9            9           8-9              8         8-9             9             9-9
GLOBAL
JUDGEMENT                 8             7-9           9           9-9           8             7-9       8          7-9           8          8-9            9           8-9              8         8-9             9             9-9
AGREEMENT                 8             7-9           9           9-9           8             8-9       8          7-9           8          8-9            9           8-9              8         8-9             9             9-9


 Table 3 - Frequency distribution of positive and negative evaluations by individual item pre and post implementation

                                                                                                COMMUNICATION                                                    CLINICAL                   HUMAN/PROFESSIONAL
                                      CONTEXT                 ORGANISATION                                                       CONTENT
    ITEM HANDOFF                                                                                    SKILLS                                                     JUDGEMENT                        QUALITIES

                                                    p-
                              NEG         POS      value
                                                             NEG          POS       p-value     NEG    POS      p-value    NEG       POS     p-value     NEG       POS        p-value       NEG           POS         p-value

           PRE-
     IMPLEMENTATION              48       160        <
                                                              3           205                     6    202                  5        100                   2       206                       4            204
          POST                                     0.001                            0.08                        0.01                          0.02                            0.16                                    0.05
     IMPLEMENTATION              0        208                 0           208                     0    208                  0        105                   0       208                       0            205




                                     Corrisponding author:                                            11                                           Submission received: 08/04/2022
                                     Stefano Maiandi: stefano.maiani@asst-lodi.it                                                           End of Peer Review process: 17/05/2022
                                     ASST di Lodi                                                                                                            Accepted: 18/05/2022
                                     Piazza Ospitale 10, 26900 Lodi - Italy       Via Festa del Perdono 7, 20122 Milan, Italy
                                                                                                                                      This work is licensed under a Creative Commons
                                      Dissertation Nursing 1 (29/07/2022)                                                             Attribution-NonCommercial-NoDerivatives 4.0 international
