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The Patient Handoff Game

For Smoother Report and Fewer Communication Glitches, Borrow Team Exercises From Improv Theater

You’re a bedside nurse, so handoffs are part of your daily routine. Most of the time, they’re just that — routine. Sometimes, though, important details get lost in translation.

Consider this fictional scenario:

Last night, Jill, a staff nurse on the med-surg floor, admitted a male patient named Smith through the emergency department. At the time of the transfer, the ED nurse told Jill that Mr. Smith had reported persistent vomiting and a 102-degree fever. Although the ED nurse made no mention of other symptoms, the patient’s wife mentioned to Jill that Mr. Smith’s left shoulder had also been bothering him.

Tonight, on her way into the unit to begin her 11–7 shift, Jill sees Mrs. Smith on a couch in the waiting area, crying. Jill stops to ask what’s wrong and Mrs. Smith says, “They just rushed my husband into surgery for some kind of heart problem. I’m so worried!”

Jill thinks back over the previous handoffs: the transfer from the ED and her own handoff to the day nurse. Did the ED nurse tell her about the shoulder pain or was it only the patient’s wife? Did Jill think to mention it to the day nurse to follow up? Jill isn’t sure, but now the patient may suffer for this communication lapse.

In the above scenario, an important bit of information was lost during one or more handoffs: Mr. Smith’s shoulder pain, which was probably a symptom of his heart trouble. We can see several points where that information may have been omitted. The Smiths may not have mentioned the pain to the ED nurse (and Mrs. Smith may not even have been present for the initial assessment). The ED nurse may not have thought to mention it in her report. Jill may have forgotten to mention it to the day nurse. The day nurse might not have thought it important enough to follow up.

Wherever the lapse occurred, it caused the care team to miss a potentially vital detail, costing Mr. Smith valuable time. With life-threatening conditions like cardiac arrest or stroke, any delay could mean the difference between life and permanent impairment or death.

Communication Pitfalls

As the Institute of Medicine illustrated in their landmark 1999 report, To Err Is Human, handoff errors are a major contributor to adverse events, from medication errors to patient death. The Joint Commission has even issued a Sentinel Event Alert (No. 58) about communication errors and how to avoid them. (You can download it from www.jointcommission.org)

While it’s easy to point fingers when such errors occur, the reality is that handoffs, like all human interactions, are often messy, fluid and subjective. Even if you say all the right things, the listener might miss important details. Maybe you spoke too quietly in a noisy environment. Maybe the listener got overwhelmed. Maybe they just didn’t grasp that something was important until it was too late.

Nursing Education

As a communications specialist, I’ve observed several basic rules that apply to most human interactions:

  • How we convey a piece of information often says as much as the information itself.
  • Specific pieces of information are easily lost or distorted.
  • Effectively transmitting just three pieces of information requires tremendous concentration from both speaker  and listener.

These rules apply even when the stakes are low and the situation calm. Add in the noise, chaos and stress of a hospital shift change and it’s easy to see how things can go very wrong.

Medical Improv

Fortunately, handoffs and other high-stakes communications are a skill that we can improve with practice. One effective way to do that is with a set of techniques known as medical improv. As the name implies, medical improv takes its cues from improvisational theater. I’ve been integrating improv activities into workshops since 2012 and have found them to be powerful tools for improving professional communication skills.

Since then, I have conducted a variety of medical improv workshops across the country. They’re easy to teach and can be helpful in bridging the gap between intellectual knowledge and behavior change.

Physical Phone

One of the improv techniques I use in my workshops is an activity I call “Physical Phone.” It’s based on the “Telephone” or “Gossip” game many of us played as kids, where each player whispered something to the person next to them and then saw how the message changed between the first person and the last. “Physical Phone” is similar, but involves the transmission of three physical gestures down a line of people.

Here’s how it works:

  1. Gather a group of people. A good starting number is 10 to 12, although once people are familiar with the game, you can add more.
  2. Tell everyone at the outset that this is a nonverbal activity and it is okay to laugh!
  3. Have the players line up single file, facing a wall.
  4. Ask the person at one end of the line to think of three distinct physical gestures in a specific order.
  5. The first person taps the person next to them on the shoulder, signaling that person to turn to face them.
  6. The first person then demonstrates their three gestures. They should do this only once. Once they have, they can come around to the front and watch the activity proceed.
  7. The second person in line — the one who witnessed the first person’s gestures — then taps the person next to them and repeats the three gestures as best they can. Once done, they can come around to the front.
  8. This process repeats with each of the people in the line until they reach the end. After each person repeats the nonverbal message, they can join the others up front.
  9. After everyone is done, the first person and the last person should stand next to each other in front of the rest of the group.
  10. At the count of three, they should simultaneously demonstrate both sets of gestures: the original ones and the ones the last person in line received them.

Don’t be surprised if the reaction is surprise and laughter as participants see how much the original gestures have changed as they went down the line. You should follow up by talking about how and why the nonverbal message becomes distorted and steps participants could take to reduce those misunderstandings.

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Three-Minute Report

After completing the initial activity, the group can also try variations on it, this time using verbal and written information. Try this three-stage follow-up activity:

Stage One:
  1. Divide the group into teams of three people.
  2. Create a written report for three imaginary patients, listing three simple data points for each (e.g., high fever, chest pain, dry mouth). Pick one data point for each patient and mark it with a star or exclamation point to indicate that it is the most important.
  3. Give one person on each team a copy of the fictional report. They should not show it to their teammates.
Stage Two:
  1. That person then goes into a different room with the second person on their team. (It can also be a different part of the same room so long as it’s out of earshot of the third person.)
  2. Set a timer for three minutes.
  3. The first person verbally reports to the second team member about the three patients. The first person can refer to the printed report, but should not show it to the second person. The second person may take notes if they wish.
  4. Once the timer goes off, the report must stop, whether it is finished or not. If the second team member is taking notes, they must stop writing when the timer rings.
Stage Three:
  1. Next, the first person should move out of earshot (taking the written report with them) and the third team member should join the second.
  2. Set the timer for three minutes once again.
  3. The second team member should then report to the third person, using only their memory and any written notes they’ve made. The third person can take notes, but both the report and note-taking must stop when the timer rings.
  4. After the timer goes off, bring all three team members back into the same room.
  5. Have the third team member give report to the first.
  6. The first team member should then refer to the original written report and see how closely this secondhand verbal report compares to the first — including which data points the third team member thought were most important.

The Power of Roleplay

Most of us know intellectually how good communication should work, but effective and respectful communication is not just an intellectual process. Hospitals and professional organizations can prepare endless lists of procedures and recommendations for proper handoffs, but reading something doesn’t stick with you as well as actually doing it.

Exercises like these are a great way to roleplay effective communication in a low-stakes environment that still feels realistic and that models some of the real challenges of on-the-job interaction, such as someone speaking too softly or the danger of missing some important piece of information while you’re taking notes.

We all know that in healthcare, the stakes are high and good communication is essential for safety and optimal patient experience. Improv activities like this are an engaging way to practice those vital skills, enhance teamwork and help to ensure that handoff procedures are actually followed as well as read.


Beth Boynton, RN, M.S., is an organizational development consultant specializing in communication, collaboration and culture, and the author of Medical Improv: A New Way to Improve Communication. She is currently working on a Teach Medical Improv ebook series. Reach her at .

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