Whether it is a taped or verbal handover, in a room or at the bedside, a good clinical handover requires effective communication to enable continuity of care. According to Flinders University, a handover requires a nurse to:
Here are five tips to polish your handover technique: Be organised Try to follow an organised sequence when handing over: patient details, presenting complaint, significant history, treatment and plan of care. Include clinical observations, pathology results, procedures etc. Don’t forget to highlight allergies, and relevant patient history and other medical conditions. Sometimes you may need to go back or forward but try to keep to an order so colleagues can easily follow you. Importantly, what is the plan of care for the next shift? Stay focused Stay relevant. Don’t handover everything that’s happened to a patient throughout the shift; sometimes this takes confidence and experience in knowing what’s important to leave in or out. It’s ok if not much has occurred during your shift, don’t make up for it with waffle or gossip. Reaffirm the patient’s current status and plan of care – and move on. Communicate clearly Be concise and speak clearly. Emphasis key needs or concerns, such as if the next set of observations or IV antibiotics are due imminently. Use relevant medical and nursing terminology. Avoid abbreviations or being ambiguous. If you are handing over to a new graduate or junior member of staff, explain any anomalies to a patient’s care or treatments they might be unfamiliar with. Check your colleague is listening and attentive – if they’re distracted, ask a question. Be patient-centred It’s not just the clinical information that is important, what has your patient’s mood been like? Are they flat, depressed, anxious, concerned, teary? Pass on any specific concerns or needs of your patient. If you have an intuition something isn’t right but your patient is clinically stable, mention it – trust and share your nurse’s sixth sense. Allow time Use handover time wisely. Whilst effective time management includes the clinical handover, it’s critical that all important information is relayed. Try not to rush or speak too fast, particularly for a taped handover report. Be open and encourage questions if it’s a verbal handover. If a colleague seems unsure of what you are saying, repeat or explain what you have said. Ineffective handovers can lead to adverse events, delays in care and complications. Time taken to provide an effective handover can lead to timely, quality care and good patient outcomes. This chapter provides a brief overview to the background of the research and the relevant literature. A short section summarises the knowledge about the extent of preventable harm to patients (see Harm to patients). The following two sections describe key insights about risks posed to patient safety resulting from handover and communication failures in different care settings (see Handover as a risk to patient safety) and specifically in emergency care (see Handover and communication in emergency care). The chapter concludes with a description of identified research gaps (see The need for further research) that informed the development of the present study. It is now widely recognised that patients across all health-care systems may suffer preventable harm resulting from inadequate care provided. Since the publication of the landmark Institute of Medicine (IoM) report To Err is Human4 in the USA, and the UK Department of Health report An Organisation with a Memory,5 there has been a significant increase in research about patient safety and the factors that contribute to or adversely affect the delivery of safe care to patients. The IoM report included earlier findings of the Harvard Medical Practice Study6 that studied 30,000 discharges from 51 hospitals in New York State and concluded that around 3.7% of patients had suffered an adverse event during the course of their treatment. Around half of these were found to be preventable. The IoM report extrapolated these figures and estimated that there may be as many as 98,000 deaths in the USA resulting from medical error. Since, further studies in the USA as well as in other countries, including the UK, have found similar and often slightly higher figures.7–12 There is now available a wealth of research from different medical specialties and different countries that indicates that health care is a high-risk domain where patients may be harmed, for example in surgery13,14 or medicines management and prescribing.15,16 In addition to causing needless harm and suffering to patients, poor-quality health-care provision has significant financial implications for the health systems. In the UK, a study estimated that preventable adverse events could cost the NHS £1B annually in additional bed-days alone.8 A report published by the Health Foundation compiles further evidence illustrating some of the costs associated with poor quality in health care.17 For example, the costs to the NHS associated with adverse drug events are estimated to be around £0.5–1.9B annually. Handover denotes ‘the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis’.18 Handover may occur between members of the same profession, for example during nursing shift change, or between individuals belonging to different medical professions or even different organisations, such as the ambulance service handover to the ED. Handover is a frequent and highly critical task in clinical practice, as it ensures continuity of care and provides clinicians with an opportunity to share information and plan patient care.19 Handover is often regarded as a unidirectional activity, for example in analogy to sports as ‘passing the baton’ or similar. Ideally, however, handover should be thought of as a joint activity and a dialogue that creates shared awareness and provides an opportunity for discussion and error recovery as participants bring different perspectives and experiences to this interaction.20–24 This includes not only the ‘telling of the story’ by the person giving the handover, but also interpretation and confirmation of the story, and the development of a mental model by the recipient of the handover, which allows seamless transition of care.22 In addition, handover can serve further functions other than simple information transfer. These may include aspects of training, socialisation, and enhancing teamwork and group cohesion.23,25 Communication failures are a recognised threat to patient safety.4 In 2009, Johnson and Arora26 wrote that ‘the buzz generated by these [research, policy and improvement] efforts has resulted in handovers jostling for top position as one of the hottest topics in the global patient safety arena’. There is certainly now a large body of evidence, including a number of systematic reviews that suggest that inadequate handover practices are putting patients at risk.27–31 Inadequate handover can create gaps in the continuity of care and contribute to adverse events.32 A report prepared by the Joint Commission states that breakdown in communication was the leading root cause of sentinel events reported during 1995–2006.33 The report further suggests that miscommunication during handover between medical providers contributed to an estimated 80% of serious medical errors.33 A survey of 161 internal medicine and general surgery physicians in training in one US hospital found that 59% of respondents reported harm to one or more patients caused by inadequate handover, and 12% reported that the resulting harm had been major.34 A survey of physicians in training on an acute paediatric ward found that in 31% of the surveys received the physician on call during the night reported that something happened for which they were not adequately prepared. The study suggests that these may have been linked to inadequate handover, as the quality of handover was rated below average on nights when something happened.35 Some of the consequences and adverse events associated with inadequate handover include hospital complications and increased length of stay following multiple handovers,36 treatment delays,20,37 repetition of assessments,38 confusion regarding care,39,40 inaccurate clinical assessments and diagnosis and medication errors,41 and avoidable readmissions and increased costs.33 The existing literature on communication and handover in health care identifies a large number of contributory factors that may lead to inadequate handover. These include the following. A frequently identified contributory factor is the absence of adequately structured handover processes.26 Interviews conducted in an Australian hospital found that 95% of participants did not identify a formal procedure for shift-change handover.38 A qualitative study comparing handover practices to pit stop practices in motor car racing concluded that handover had no clear procedures and was not supported by formal checklists.42 A focus group-based study involving junior doctors found that shift handover was perceived as frequently being conducted in an ad hoc or chaotic fashion, and without obvious leadership.43 Another contributory factor discussed in the literature is missing and inaccurate documentation, or inadequate reliance on documentation. A study observing nursing handover of 12 simulated patients found that purely verbal handover resulted in information loss fairly quickly, whereas verbal handover supported by a typed handover sheet suffered only minimal information loss.44 On the other hand, the use of such handover sheets may potentially make the handover more vulnerable by detracting from the focus on the most relevant items.45 Over-reliance on medical records was reported in a study that investigated handover and communication between doctors and nurses.46 This study found that often there was inadequate communication, and, as a result, there were disagreements on issues such as planned medication changes (42%), planned tests (26%) and necessary procedures (11%). Although the content of handover has been studied frequently, less is known about how non-verbal behaviour influences the quality of handover. A recent study in a number of US Department of Veterans Affairs (VA) medical centres investigated types of non-verbal behaviour in nursing and physician handover. The authors concluded that participants frequently adopted forms of non-verbal behaviour that may result in suboptional transfer of information.47 Such forms of non-verbal behaviour included holding patient lists or other artefacts in such a way that they could not be seen by the other participant (‘poker hand’), not having a joint visual focus (‘parallel play’) and situations where the person giving the handover was standing while the other party was sitting, which resulted in hurried handovers with fewer questions (‘kerbside consultation’). The most productive form of non-verbal behaviour was reported to be the joint focus of attention, where both parties co-ordinate their verbal and visual attention jointly on an object. The literature suggests that a lack of organisational priority given to handover, and the absence of formal training in communication and handover both at universities as well as within health-care organisations are further barriers to the implementation of effective handover.26 A recent interview study investigating transitions from primary care into hospital suggested that participants perceived handover as an administrative burden that took away time for their patient care duties. The study also found that handover and communication competencies were rarely taught, and that clinicians learned these skills ‘by being around and immersed in the clinical effort’.48 A national survey of internal medicine training programmes in the USA found that 60% of these did not provide training in handover.36 One study reports that junior doctors had not received any training in handover, and that, as a result, they had a narrow view of handover concerning only completion of outstanding tasks.43 Arora et al.49 present a competency-based approach to improving handover that entails the development of a standardised instructional approach to teach communication skills and the establishment of corresponding robust assessment systems. The most frequently encountered recommendation for improving handover communication is that of standardisation through procedures, checklists or mnemonics, and appropriate training in their use.31,42,49,50 Standardisation may simplify and structure the communication, and create shared expectations about the content of communication between information provider and receiver.51 The Joint Commission introduced in 2006 a requirement for organisations to implement a standardised approach to handover.28,52 The specific communication protocol recommended is situation, background, assessment, recommendation (SBAR),53 which provides a general order to topics.51 A review of different handover mnemonics found that SBAR was the most favoured approach in practice.31 As part of a simulation study, final-year medical students were taught the SBAR approach. The study found that this improved their handover performance during the simulation compared with students who had not received this training.54 In the UK, trauma guidelines often include now the use of the ATMIST (age, time, mechanism, injury, signs, treatments) handover tool. The NHS Litigation Authority Risk Management Standards 2012–13 require an approved documented process for handing over patients.55 This requirement stresses in particular consideration of the out-of-hours handover process, and emphasises the need for monitoring of compliance. In the ED, the risks arising from inadequate communication and handover may be even more significant than in other areas, and the environment may be more conducive to communication failures. EDs have been described as high-risk contexts characterised by overcrowding conditions that pose particular threats to patient safety, such as ambulance diversions, treatment delays owing to long wait times, and patients leaving the ED without being seen.1,56 Handover and communication taking place in such settings of high patient acuity and overcrowding are particularly vulnerable and pose significant risks not only to the patients being handed over, but also to other patients requiring urgent care.20,57 The IoM report states that ineffective handover has been identified as one of the leading causes of medical error in the ED.1 Several studies have investigated shift handover in the ED.58 An ethnographic study in five EDs found that practices varied significantly, and that they lacked structure and standardisation.24 An Australian study investigating doctors’ shift handover in three EDs using a post-handover questionnaire and a survey tool found that in around 15% of cases required information was not handed over.39 The missing information related predominantly to aspects of management, investigations and patient disposition. Participants stated that this resulted in repetition of assessments and delay in management of the care. The study found that handover failures were particularly likely for patients with longer stays in the ED, who received multiple handover. There has been less research investigating handover across organisations,59,60 although this is starting to change. This area is of particular importance because of cultural differences, often high levels of uncertainty and absence of clear diagnosis, pending test and investigation results creating opportunities for omission, and the more vulnerable state of the patient, for whom delays or other handover failures may have serious consequences.60 A systematic review of the literature pertaining to handover from ambulance services to EDs published in 2010 identified eight relevant studies.27 The studies included in the review describe a number of barriers to effective handover. These include the lack of common language, perceived lack of active listening skills, lack of clear leadership, multiple repeated handovers, and inadequate environmental conditions. A subsequent ethnographic study found that the quality of handover between ACs and ED nurses appeared to be dependent on staff expectations, prior experience, workload and working relationships.61 Similar results were found by studies that investigated the transfer of patients from ED to the hospital. In a survey of ED and internal medicine physicians, around 30% of respondents reported that one of their patients had experienced an adverse event or a near-miss following transfer from ED.60 The survey identified communication problems, unsuitable work environment, information technology (IT) issues, and unclear allocation of responsibility as contributory factors. Participants in an interview study referred to the communication between ED and hospital physicians as ‘grey zone’ characterised by information ambiguity.20 The conflicting information expectations of physicians from the different specialties represented a particular barrier to efficient handover communication. Randell and colleagues62 developed a descriptive model of handover that links the strategies that the participants of the handover adopt to the different contexts within which handover may take place and to the different functions that handover can serve. They provide examples, taken from observations in eight different settings, including an EAU and Medical Admissions Unit, of how practitioners adapt their behaviour and provide flexibility to the handover in response to, for example, different workload and staffing levels or particular patient conditions. Suggestions for improvement of handover include the adoption of structured communication protocols,20,51,60,61,63,64 the creation of opportunities for interdisciplinary, interdepartmental and interorganisational collaboration,60,61 the introduction of IT across departmental and organisational boundaries,60 and the teaching of appropriate communication skills20 including shared training programmes across organisations.61 A systematic review of the literature on handover in hospitals up to 2008 argued that many of the severe risks to patient safety could be found in handover across departments, and that efforts at standardisation that are confined to departments may even exacerbate the situation for interdepartmental handover.28 The review concluded that there was no reliable body of evidence that standardisation of handover provided sustainable improvements in patient outcomes. This insight and the brief review above suggest that current research is limited by its predominantly narrow focus on transfer of clinical content and the adherence to a standardised communication protocol,26,50,65 and the equally narrow focus on shift handover or handover within a single department.48,66 Further research is required that addresses the following:
Chapters 3 and 4 describe in detail how the research project contributed to each of the two domains identified above. |
Why is it recommended that verbal handover is supported by documentation such as handover sheets.
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