Intrahospital Handovers before and after the Implementation of ISBAR Communication: A Quality Improvement Study on ICU Nurses’ Handovers to General Medical Ward Nurses

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Comments for author File: Comments.pdf

Author Response

Response to reviewer 1.

We are thankful for your valuable contributions and hope that our responses are to your satisfaction. Revisions in the manuscript are in red.

Title

Comment 1:  In my opinion, and especially in many author guidelines, acronyms should be avoided in the title. However, I realise that in this case, for editorial reasons, the full acronym can hardly be inserted in the title.

Response 1: We agree, as this acronym would be too long to include in a title, and the acronym is quite well known as an acronym for structured communication.

Abstract

Comment 2: The length of the abstract does not comply with the authors' guidelines (The abstract should be a total of about 200 words maximum): please adjust it.

Response 2: Agree, the abstract is now revised and complies with the guidelines stating that the abstract should be about 200 words maximum. Now the abstract consists of 187 words.

Comment 3: Acronyms are not recommended in abstracts. However, in my opinion, they should be given in full the first time.

Response 3: Agree. We have now explained the acronym. See line 18.

Comment 4: Line 17: The name of the paragraph does not comply with the authors' guidelines.

Response 4: Agree. This is now updated in line 19.

Results: Comment 5: Too long in my view.

Response 5: Agree. The result section is now shortened.

Comment 6: Line 26: The name of the paragraph does not comply with the authors' guidelines.

Response 6: Agree. This paragraph complies now with the guidelines, see line 26.

Comment 7: Conclusions too long in my view. The abstract is overly informative.

Response 7: Agree. The conclusion is now shortened, and the abstract contains 187 words. 

Introduction

Comment 8: Perhaps the introduction could provide some additional information on the chosen instrument.

Response 8: Information about the instrument is outlined in the Material and Methods section, and more information about the validation of the instrument is now added.

Comment 9: Line 40: Please update Bibliographic References.

Response 9: Agree. A research librarian has now created a reference style for Nursing Reports, and hopefully this have updated the references to your satisfaction. Arora is updated with a new year, reference nr. 1.

Comment 10: Lines 40-41: “These situations rank among the five most common causes of adverse patient events and unnecessary medical costs”: Can we draw such important statements from the cross-sectional study of Reine et al., 2019? It would also be interesting to know the other four causes.

Response 10: Agree, this reference is now replaced with the original reference, and we have also added the other areas that can promote patient safety, see line 36-42.

Comment 11: Lines 44-45: “The Joint Commission asserts that 80% of adverse events involve miscommunication during handovers [8]”. A terrifying figure for patient safety!

Response 11: Agree, but so the source say.

Comment 12: Lines 47: Can you update citation 9?

Response 12: Agree. This citation is now updated.

Materials and Methods

Comment 13: Design Lines 101-103: The research questions have already been reported after the aim of the study. I would suggest removing them from this section.

Response 13: Agree. A new section called Aim is now included in the paper in accordance with the SQUIRE guideline, see line 110-116. The academic editor wants us to report this study as a quality improvement study.

Comment 14: The ISBAR intervention Who are the authors of the videos? Could videos be added as supplementary material? In my opinion, it could be useful.

Response 14: Two of the authors were responsible for developing the videos and their content. The videos are in Norwegian, but a texted English version may be available if this is interesting for an international community.

Comment 15: What are the sources of the information material provided to nurses? For what purpose were mouse pads delivered? A bullet-pointed list?

Response 15: The sources of the information material was based on the evidence-based literature search. The purpose of the mouse pads was to remind nurses using ISBAR communication, now outlined in line 186.

Comment 16: Line 136: Mars: perhaps you mean March?

Response 16: Agree and now updated.

Instrument

Comment 17: I tried to find validation study 38, but it seems to have been published in the original language. In my opinion, this is a strong limitation for the international community and related knowledge. If so, in my opinion, it would be a strong limitation. Alternatively, could the authors provide a reference for the English study?

Lines 143-143: Readers worldwide should be able to verify these claims to assess the tool's reliability. Please compare the previous suggestion.

Response 17: The validation study is published in the original language, but we have provided some more information about the validation process in line 193-197. We have addressed this limitation in line 350-354. The English study reports results from another study using another questionnaire.

Results

Comment 18: Some sentences in this paragraph are outside the Results section and should be moved to the Discussion section. In my opinion, the results section could be improved, and the paper should be adapted more strictly to the guidelines for authors suggested by the journal.

Response 18: We believe we have reported the results objectively, and don’t understand which sentences you mean belong to the discussion section.

Discussion

Comment 19: Line 205: Please add the reference of the 26-item ISBAR communication scoring tool.

Response 19: The introduction to the discussion is now changed based on the academic editor suggestions on the study design, and therefore the sentence referred to in the comment is now replaced.

Comment 20: Lines 202-209: Do you think that the lack of significant improvement between pre-test and posttest readings may also be due to the timeframe between training and post-test readings as mentioned in the limitations?

Response 20: We agree that this also may be an explanation, and is now added to the manuscript, line 264.

Comment 21: From a methodological point of view, I would not bring the studies mentioned in the introduction back into the discussions.

Response 21: We believe we have only used highly relevant studies from the introduction to discuss our findings according to other findings. Besides, new literature is also added.

Comment 22: The items with a drop in the post-test are very important, perhaps, in my opinion, more so than the improved ones. Too bad.

Response 22: Agree, and this is also highlighted in the discussion section.

Comment 23: Do the authors know the percentage of ‘non-applicable’ choice in the study?

Response 23: No, and this is highlighted in the discussion section and represent a limitation to the study.

Comment 24: NEWS: The acronyms should be given in full the first time.

Response 24: Agree, this is now added in line 299.

Comment 25: Lines 248-250: “In our study we found that treatment limitations were not stated in any of the handovers in the pretest, but this number raised to three of the handovers in the posttest”: The asynchronous detections and the small sample size do not, in my opinion, support the hypothesis of the effectiveness of the intervention in this area. To this end, rigorous efficacy studies should be conducted, as mentioned in the limitations.

Response 25: Agree. This result was just a description about what was reported in the observed handovers.  and making any assumptions on this result is now addressed as a limitation in the manuscript. See line 314-316.

Comment 26: Lines 266-268: “However, there is a need for well-performed clinical trials to conclude that handover tools do, in fact, improve patient safety during the handover process from ICU to general wards [34]”. I agree.

Response 26: Thank you.

Comment 27: The Discussions relate the findings of this paper to existing knowledge. In my opinion, the practical implications should be emphasized.

Response 27: We believe we have highlighted practical implications in line 326-331, as we suggest that the ISBAR communication scoring tool can improve patient safety by improving the handovers content and structure.

Limitation

Comment 28: Well done section. However, I confirm my doubts about the validation process of the original instrument. Furthermore, the guidelines for authors of this journal suggest that it should be included in the Discussion section.

Response 28: We believe that discussing limitations also belong to the discussion section of an article, and methodological issues mentioned in your comment is addressed in this section, see line 346-355. In addition, some more information about the validation process is added to the manuscript, see response 17.

Conclusion

Comment 29: Could the field notes be a less than-objective element to ascertain an improvement after the intervention?

Response 29: Agree, this is now highlighted in line 362.

References

Comment 30: In my opinion, the bibliography could be streamlined and updated in some cases.

Response 30: Agree. A research librarian has now created a reference style for Nursing Reports, and hopefully this have updated the references to your satisfaction.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors, I enjoyed reading your article and would like to give my contributions as a reviewer.

The article addresses a crucial topic in nursing practice: communication during patient handovers. The implementation of the ISBAR model seems to contribute to improved communication in the area under study (intra-hospital handovers). The study is relevant, especially in a context where the complexity of intensive care requires clear and concise information exchange.

The overall methodology adopted for the study is appropriate and follows the STROBE guidelines that is a positive aspect. The most problematic issue I see is the sample size. The justification given that a power calculation was performed, indicating that a sample of 25 participants would be sufficient to detect a significant difference between the pretest to the posttest with an effect size (Cohen's d) of 0.80, does not seem adequate. An effect size of 0.80 is considered large, suggesting that the sample should be able to detect substantial differences, if they exist. From the description of the results, we perceive that the effect was small to moderate, which means the sample size should have been larger. If the sample size was calculated using, for example, G Power, with the following specifications: two tails, effect size 0.5 (moderate), alpha 0.05, power of 0.8, 34 participants would be needed, which is more than the number studied.  

In the provided text, there is no explicit mention that the participants are the same before and after the intervention. It is necessary to determine whether the 25 nurses involved in the 50 handovers are the same before and after intervention (they seem to be, but it is important to state this explicitly). This clarification is important. If the participants were the same, statistical tests should be for paired samples rather than independent samples. Instead of the chi-square test, you could use the McNemar test, and instead of the Mann-Whitney, you could use Wilcoxon test.

Regarding the CVI (Content Validity Index), its full meaning should be presented in the text.

In the presentation of Statistical Analysis, it is not common to reference the presentation of results by indicating tables 1 and 2.

The results are clear and detailed. The discussion addresses the main findings.

The article acknowledges several limitations, such as the possibility of observer bias and the influence of the researchers' presence on the nurses' practices. These limitations are important and should be considered when interpreting the results. The suggestion for future research with more intensive and multifaceted interventions is valid and necessary to deepen the understanding of the effectiveness of ISBAR. However, the issue of sample size was not addressed.

The conclusion highlights the importance of structured protocols such as ISBAR.

Comments for author File: Comments.pdf

Author Response

Response to reviewer 2

We are thankful for your valuable contributions and hope that our responses are to your satisfaction. Revisions in the manuscript are in red.

Response 1: Thank you.

Response 2:

We agree that the sample size may be too low to detect a difference between baseline and post-intervention. We didn’t use G Power to calculate the power, but a model from Polit and Beck (2017), as described in the original draft. Based on recommendations from the academic editor suggesting that this study should be reported as a quality improvement study, we have removed the power-calculation from the text. However, we have addressed that our results may be due to an underpower study in line 265.

We agree that the manuscript was not clear enough about whether the participants were the same at baseline and post-intervention. This is now made clearer, se line 211-213.

The full meaning of CVI is now presented in line 197-198.

We have now removed references to Table 1 and Table 2 under the statistical analysis section.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

I thank the authors for this interesting article, which I believe is useful for the nursing profession. Below, I attach my comments to improve this manuscript:

• Introduction: I would describe the ISBAR tool in more detail.
• Materials and Methods: The study aligns with the STROBE guidelines. Could the authors provide the STROBE checklist?
• Citations: Citations 3, 5, and 9 are not recent. Can they be replaced with more current citations?
• Methodology and Results: I find these sections well-structured and clear.
• Discussion: In lines 207-209, I would expand the discussion about the fact that the results revealed no significant improvements from the pretest to the posttest.
• conclusion: section well-structured and clear.

Author Response

Response to reviewer 3

We are thankful for your valuable contributions and hope that our responses are to your satisfaction. Revisions in the manuscript are in red.

Comments:

Response Introduction:

We have now provided more information on the ISBAR tool, se line 61-71.

Response Material and Methods:

Based on suggestions from the academic author on our study design, the design is now changed to a quality improvement study where the SQUIRE 2.0 tool is relevant.

Response citations:

 We want to keep these citations, because one represents a single research study relevant for our topic, and the two other represents systematic reviews.

Response discussion:

Agree. We have now expanded the discussion by adding barriers to the discussion, see line 265-274.

Response conclusion:

Thank you.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the detailed answers. In light of the changes made, the study has been improved for publication.

Reviewer 3 Report

Comments and Suggestions for Authors

the authors made the requested changes. The manuscript can be published