An obstacle that nurses would face in practicing effective hand-off communication is culture, as mentioned in the Roles and Participation section of this project. Sullivan adds that "cultural attitudes, beliefs, and behaviors affect communication". 
     Another cause of limited participation would be a nurse's listening skills (Sullivan, 2013). He or she could lack self-confidence, and their mind could be racing--instead listening to the information conveyed--because they are nervous. The recipient nurse could also be approaching the end of his or her shift, receiving a transfer patient on the unit. With such little energy left, his or her attention might not be fully focused on all the details given in report. 
     On the other end of the communication spectrum, other than listening, nurses can have barriers in speaking that interfere with how they give hand-off. "Most speakers overestimate how clearly and effectively they communicate. Speakers assume that the receiver has the same knowledge that the speaker possesses, and the better you know the receiver of a hand-off, the more you may overestimate the quality of what you have communicated and how much the receiver already knows" (Reisenberg, 2012). In order to get over this barrier, nurses will have to give the same information to everybody as if he or she didn't know them. Although it is acceptable to have a rapport and relationship with fellow co-workers, when communicating about patient information, stay focused on the task in order to keep their safety a priority.
     The last barrier to a strong hand-off is human memory. "Memory is affected by personal biases, current mood, how tired or rested you are. The receiver simply accepts as fact what the sender said, without critically evaluating the evidence" (Reisenberg, 2012). Our memories will always be flawed, which reinforces the importance of using a standardized communication tool or template to record information throughout the day. 

     Related to hand-off communication, some nurses are improving the issue while others are worsening it. Many factors play into how people communicate and how receptive others are to that information. One aspect in particular, culture, can act as a downfall when it comes to nurses' interpretation of others' communication attempts. "Body movement, gestures, and tone are culturally defined. A great deal of misunderstanding results from a lack of understanding of each other's cultural expectations" (Sullivan, 2013). There are nurses out there who incorporate cultural competence in their practice, and these individuals continue to improve hand-off communication. However, not everyone is aware nor open-minded to other cultures' communication styles, which worsens the issue. While it is an unreasonable goal to be aware of every single culture's communication style, it would positively benefit a nurse's practice by becoming familiar with the cultures commonly seen at his or her workplace.

     As previously mentioned in the Literature section of this project, the lack of structure posed as a negative influence on hand-off efficiency and efficacy. A major way that nurses can involve themselves in improving the issue of inadequate hand-off communication is by standardizing their information delivery. The Institute for Healthcare Improvement states that "teams can promote safe and efficient hand-overs by having an effective, standardized process. Having a plan for clear communication helps teams deliver appropriate care in any scenario" (Institute for Healthcare Improvement, 2019). 
     Two standardized communication tools recommended by the Joint Commission include ISBAR and I-PASS (Joint Commission, 2017). ISBAR stands for: Introduction, Situation, Background, Assessment, and Recommendation. I-PASS stands for: Illness severity, Patient Summary, Action List, Situation awareness, and Synthesis by the receiver. 
On top of incorporating the use of standardized communication tools to improve hand-off efficacy, nurses can maintain the Joint Commission's 2008 Hospital Patient Safety Goals: 

●"Find an appropriate time to discuss the problem, scheduling an appointment if needed 

● State the problem clearly and explain why it is interfering with work

● Listen to the supervisor’s response and provide more information if needed

● If I agree on a solution, offer to do my part to solve it. If I cannot--discover an agreeable solution, schedule a follow-up meeting, or decide to gather more information

● Schedule a follow-up appointment" (Sullivan, 2013). 

It is important to maintain an honest, open, and collaborative relationship with our supervisors because in the end, they will be the ones managing our workspace. Keeping clear communication will foster improvement and growth in everyone's interpersonal skills.