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Placing patients at the heart of nurse handovers

Nursing handovers between shifts on cancer wards have traditionally been badly organised and unproductive, says nurse researcher Lena Sharp.

Nursing handovers between shifts on cancer wards have traditionally been badly organised and unproductive, says Lena Sharp, who works as a senior researcher at the world-renowned Karolinska Institute.

When nurses have had bad shifts they tend to focus on that rather than concentrating on sharing knowledge about the patients, and deciding what should be happening on the next shift. Patient safety literature and research studies have highlighted criticism of this from the past ten years, saying that handovers are often ineffective because they have no real structure.

Handovers on acute cancer wards have traditionally not involved discussions with patients

Perhaps the biggest flaw of all is that patients are rarely involved in the handovers. Dr Sharp, who is also head of

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Nursing handovers between shifts on cancer wards have traditionally been badly organised and unproductive, says Lena Sharp, who works as a senior researcher at the world-renowned Karolinska Institute.

‘When nurses have had bad shifts they tend to focus on that rather than concentrating on sharing knowledge about the patients, and deciding what should be happening on the next shift. Patient safety literature and research studies have highlighted criticism of this from the past ten years, saying that handovers are often ineffective because they have no real structure.’


Nurses must work together with patients to ensure all involved are up to date with care. Picture: iStock

Handovers on acute cancer wards have traditionally not involved discussions with patients

Perhaps the biggest flaw of all is that patients are rarely involved in the handovers. Dr Sharp, who is also head of cancer care improvement at the Regional Cancer Centre in Stockholm-Gotland in Sweden, says handovers are typically carried out at nurses’ stations, which means there is no patient input into decisions about changes to medication or other aspects of care.

There is little research evidence on best practice for handovers. One review (Vines MM et al 2014) found a link between the use of bedside handovers and increased patient and nurse satisfaction, although this does not involve cancer patients. 

Dr Sharp says: ‘Nursing handover is a complex and overlooked process. There is little consensus on which handover style works best, where handovers should take place, how they should be structured, what they should include or who they should include.’

Patient involvement

To try to build an evidence base of her own she has analysed the role of patients in handovers, and tested a new handover model. One study from 2014 (Kullberg et al) investigated patient experiences of traditional handover models and the degree that nurses and other health workers exchange information with patients on cancer wards about their care.

The academics found that only half of patients subject to medication changes were aware any alterations had been made.  The researchers also discovered that staff had documented fall prevention strategies for 30 patients, but that half of these said staff had never actually discussed the risk of falls with them. Dr Sharp and her co-authors suggested that if patients had been involved in staff discussions during handovers then the risk of falls could have been reduced.

Dr Sharp was recently part of a linked study testing whether a person-centred handover (PCH) could improve patients’ satisfaction levels. The five-stage PCH begins at the nurses’ station, where the nurse coordinator of the morning shift allocates patients and provides a printed list for each member of the evening shift, including patient names and diagnoses. The nurse about to start the shift reads the admission notes in the electronic health record, then the nurse from the morning shift goes to the bedside and introduces the patient and family members to the new nurse, and invites questions. The incoming nurse talks about the care planned for the next few days – avoiding medical jargon where possible.

Research shows that doing handovers at patients’ bedsides are beneficial

Information exchange

This information exchange gives incoming staff the chance to gain first-hand information from patients, family members and colleagues. Patients are encouraged to ask questions during this stage and throughout. The morning shift nurse then does a safety check at the bedside, which includes ensuring that patients have the correct ID wrist band, checking fall risk factors and taking any preventive actions. There was also a check on medication to see that ongoing infusions, for example, were in line with prescriptions.

The research team compared patient satisfaction levels on wards using PCH techniques with those using the traditional, unstructured, non-verbal style of handovers conducted via an electronic health record in the absence of the patient. This was for handovers between morning and evening shifts.

Patients were asked a series of questions about their satisfaction levels, and satisfaction scores were calculated from the responses. Overall, the research team found no significant differences in satisfaction levels between the PHC ward and control ward, although patients on the PHC ward did record better scores regarding their evaluation of how well information about them was exchanged between health workers.

Components of the patient-centred handover model

  • Preparation – giving nurses details about their patients and their diagnosis.
  • Introduction – the on-shift nurse introduces the incoming nurse to the patient and his/her family and friends.
  • Information exchange on care planned for the shift.
  • Patient involvement – patients are encouraged to ask questions.
  • Safety check – medication changes, infusions planned for the next 24 hours, falls risk assessment and prevention.

 

Dr Sharp says: ‘Patient-centred care shifts the power and is respectful of individual patient needs. It creates a partnership between the patient and healthcare professional.’

She acknowledges that there are challenges in involving patients in handovers. If handovers take place early in the morning, some patients might prefer to sleep than be woken up and involved in shift handovers.

Another difficulty with the PCH approach is that it is difficult to evaluate, partly because patients generally stay in hospital only for a short time, says Dr Sharp. Also, there is a ‘lack of instruments and robust outcome measures’ to analyse the impact on patient safety, she adds.

Academic Lena Sharp argues that falls risk may be reduced if patients are involved in handovers

She admits that more research needs to be done into what kinds of handovers work best, but in the meantime, she remains convinced that PCH methods are the way forward.

‘Anecdotally we’ve had many positive comments from patients, family members and staff. It is a major change in practice, though, so staff do need to be trained and educated beforehand in how the system works. This could involve lectures, workshops and role play. Nurses need to have excellent communication skills to make PCHs work. It can also be difficult to include all the things on the checklist because nurses are busy, but it is important to consider them all.’

If nurses can embrace these techniques there will be benefits, she adds. ‘Many nurses currently have a task-oriented view on medication administration and other clinical procedures, and they miss opportunities on a daily basis to exchange information with patients that could greatly improve care quality and safety.’


References

  • Kullberg A, Sharp L, Johansson H et al (2014) Information exchange in oncological inpatient care – patient satisfaction, participation, and safety. European Journal of Oncology Nursing. doi.org/10.1016/j.ejon.2014.10.005
  • Kullberg A, Sharp L, Johansson H et al (2017) Patient satisfaction after implementation of person-centred handover in oncological inpatient care – A cross-sectional study. PLoS ONE. 12, 4, e0175397.
  • Vines MM, Dupler AE, Van Son CR et al (2014) Improving client and nurse satisfaction through the utilization of bedside report. Journal for Nurses in Professional Development. 30, 4, 166-173.

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