How to make handovers more effective
Rethinking communication during handovers can improve patient safety and reduce staff stress
Handovers are an essential part of everyday nursing practice and a key part of ensuring patient safety, yet many happen at the end of a shift when staff are tired and waiting to go home.
‘We know from feedback that what makes nursing staff stressed and upset about their work patterns is always having to finish late, but often it’s because they want to give a good handover and they want to make sure they get it right,’ says RCN head of nursing practice Wendy Preston.
According to the RCN’s safer staffing survey, published last year, 65% of the more than 30,000 staff who responded said they worked additional time. A quarter said they worked an extra hour or more on their most recent shift.
‘I remember being in clinical practice and going home feeling that handovers were rushed and I didn't have enough time,’ says Ms Preston. ‘You leave work asking yourself whether you’ve forgotten anything. And we know that doesn’t lead to a happy and healthy workforce.’
A need for governance
She argues that handovers need the robust governance that is characteristic of other elements of nursing practice.
Jane Bruton, clinical research manager in the Patient Experience Research Centre at Imperial College London and a nurse for almost 40 years, would also like to see a more structured approach to handovers.
‘We’re not taught how to do it and there’s no competence measures for handovers,’ says Ms Bruton. ‘I’ve done it for years but really only learned by watching others. No one has ever said “this is how we do handovers here, this is the philosophy behind it, and here’s what we’re trying to achieve”. It’s odd that such a central aspect of communication remains fairly unstructured.’
But she argues against any kind of ‘one size fits all’ model, citing research she was involved with, which looked at patient and staff experiences of nurse handovers. ‘What we recommended was that you can’t standardise the practice because different areas have different needs,’ she says. ‘But what does help is your ward or area agreeing on the purpose of a handover and what style you’re going to use based on your values and the setting.’
This should then be communicated to all the members of the multidisciplinary team and, crucially, to patients too, says Ms Bruton. ‘Our experience was that patients were often much clearer about what a ward round was and they were unsure about handovers. Some weren’t even aware of it happening,’ she says.
Six ways to improve communication in handovers
- Ensure handovers are planned, advises the RCN’s Wendy Preston. ‘Be prepared and make the time for a good handover. Remember: right person, right place, right time.’
- Work towards a shared model or understanding of what will be provided and what is expected during a handover, advises David Fitzpatrick, senior lecturer in health sciences at Stirling University. He suggests agreeing an appropriate mnemonic that everyone uses. ‘It’s not really that important which you choose, but that you’re all using it with a shared understanding,’ he says.
- Look at ways of improving communication between members of the multidisciplinary team, particularly medical staff and nurses, says Ms Bruton. ‘Make sure there is always a nurse on the ward round – this still doesn’t happen everywhere,’ she says. ‘And have a point in the day when doctors provide feedback for nurses so they are fully able to handover to the next shift, otherwise information can get lost.’
- Keep handovers succinct and avoid repetition. ‘They can go on too long, with routine information, such as age and diagnosis, handed over time after time,’ says Ms Bruton. ‘The risk is that you’ll run out of time to get to the things people don’t know.’ She suggests using handover sheets that include patient information. ‘And check whether the nurse already knows the patient,’ she says.
- View handovers as a constant process rather than something that only happens at the end of your working day, says Ms Preston. ‘If your team uses a handover sheet, keep it up to date throughout your shift,’ she says. ‘It helps with your documentation too.’
- Leave enough time for queries at the end of the handover, says Dr Fitzpatrick. ‘Someone may have a specific question not answered in your handover, or they may need some clarification, and this gives them the chance to ask,’ he says. But if you’re receiving a handover, listen carefully and wait until the person has finished before you ask anything, he says: ‘Interruptions can be a distraction.’
Bedside handovers
Experiences of bedside handovers were variable, the researchers discovered, sometimes taking place outside rooms or bays. In some cases, even when patients were able to participate, they did not want to. ‘But the patient can add valuable information, especially if the nurse has got it slightly wrong,’ says Ms Bruton. ‘For example, it may have looked like someone had a good night's sleep when they didn’t. It’s not just about observations and care, but also how the patient is feeling. If care is truly patient-centred then the patient's experience of it is important.’
‘If nurses are using language in front of the patient that isn’t easy to understand, it feels very awkward’
Jane Bruton, clinical research manager, Patient Experience Research Centre, Imperial College London
Make it memorable with mnemonics
Mnemonics – acronyms that act as reminders for key information – can be used to standardise clinical handovers, helping staff to remember vital elements in their communication. Among the most frequently used are:
SBAR
This is used in a wide range of settings and by a variety of healthcare professionals, including nurses and doctors.
- Situation including the patient’s name, their consultant, their vital signs and any specific concerns
- Background when and why they have been admitted, any diagnosis, significant medical history, current medications, allergies, laboratory results and any progress since admission
- Assessment including vital signs, clinical impressions and any concerns
- Recommendation care management plan and time frame
SBAR training and implementation guide
ATMIST
Commonly used in managing trauma cases, often by paramedics handing over care to emergency department staff.
- Age and background
- Time of the incident or onset of symptoms
- Mechanism of injury or medical complaint
- Injuries or findings
- Signs
- Treatment
Among the major frustrations for patients is when they are told something by one healthcare professional, but then another doesn’t have that information. ‘A nurse will say you’re not going to able to go home today, and the patient will say “but the doctor said I can”. It looks like you don’t know what’s happening,’ she says.
‘As a patient, you want to feel that staff know what’s going on, otherwise it’s unnerving.’ Regular checking in with each other throughout the day would help, she says.
Avoiding paternalism
The choice of language is another important issue. ‘If nurses are using language in front of the patient that isn’t easy to understand, it feels awkward,’ says Ms Bruton. ‘It sets up the concept of the patient being a child and this kind of paternalistic care isn’t appropriate.
‘We’re expecting patients to go home and be able to self-care, take responsibility and manage their medication when they’ve not been involved in their care in hospital. You can’t expect them to suddenly understand everything at discharge.’
While some nurses worry that involving patients in handovers will lengthen the process, Ms Bruton believes that improving communication actually makes nurses’ working lives easier. ‘You aren’t correcting mistakes later on, which can be much more time-consuming than concentrating on getting it right from the beginning,’ she says.
'Safety huddles'
Handovers in the community present particular challenges. With their clinical handovers happening just once a week, a district nursing team in Merseyside has found additional daily ‘safety huddles’ invaluable in improving communication and delivering better patient care.
‘We designed a template as a way of trying to reduce harm to our patients,’ says district nurse team leader and Queen’s Nurse Jane Hulme, who works for Mersey Care NHS Foundation Trust. The trust provides specialist inpatient and community services for a catchment area of about 11 million people.
In practice, staff meet for about 15 minutes each morning after their first calls. ‘It’s a snapshot of the previous day and a preview of what’s coming,’ says Ms Hulme. Each session begins with a list of prioritised patients and the care they need, tracking whether it’s been delivered in a timely way – for instance, people with insulin-dependent diabetes or those nearing the end of life.
In one recent example, the team discovered that a patient who needed insulin twice daily had been missed from morning visits. A nurse was immediately dispatched to administer the medication, preventing an adverse incident.
(from left) Pauline Holmes, Julie Hughes,
Jane Hulme and Michael Turner.
Picture: John Houlihan
Pressure ulcers can also be raised at the earliest stage, with reviews usually happening within 48 hours, leading to dramatic reductions in severity. Meanwhile, patients needing specialist help can be quickly referred to other teams.
The team has also established a safety huddle handover for the evening service, sharing information about any patients who may ring for help.
While the primary aim of the huddle is to improve patient safety, staff have benefitted too, says Ms Hulme. ‘It’s provided really good support,’ she says. ‘We’re all lone workers and it can be quite daunting to go out to a patient’s house and be the only clinician, especially for staff who are new to the community and used to having others around them.’
‘Safety net’
Staff also have a forum where they can escalate and have documented any concerns, she says. This includes incidents where patients don’t seem to be at home when the team calls. ‘Now we monitor calls where staff have not been able to see a patient and a senior member of staff will find out why this has happened so we have a safety net,’ says Ms Hulme. Staff are much more relaxed and open to conversations about patients, she says. ‘And new staff feel much more able to ask questions and they are dealt with straight away.’
Since safety huddles began in summer 2016, they have been adopted by other teams in the area, including allied health professionals and specialist nursing teams, and in other parts of Liverpool.
A key challenge has been to persuade staff it’s possible to convey all the information in just 15 minutes. ‘It doesn’t replace a full clinical handover,’ says Ms Hulme. ‘But the huddles have had an effect on these too and they’re now quicker, with staff fully aware of complex patients because they are discussed every day. As a result, our weekly handovers are much slicker.’
The reusable card that standardises practice
ineffective handovers can be
associated with adverse incidents.’
David Fitzpatrick, a senior lecturer in the health sciences faculty at the University of Stirling, has led two studies looking at communication in handovers between ambulance staff and those working in critical care and A&E. ‘Improving handovers is a top priority for the World Health Organization and we know that ineffective handovers can be associated with adverse incidents, including deaths,’ he says.
His research found that many ambulance staff were relying on their memory, rather than writing things down. ‘And there are risks with that approach,’ says Dr Fitzpatrick. ‘You can forget information and that can have some significant consequences, including illnesses or injuries you forgot to mention.’
Time was identified as another pressure, with almost half of ambulance staff who responded to a survey that formed part of the research reporting difficulties in finding enough time to prepare for handovers to other clinicians.
Recording information physically was also challenging. While writing on the back of gloves is standard practice in the emergency care world, it raises a number of problems, says Dr Fitzpatrick, a former consultant paramedic who worked in the Scottish Ambulance Service for more than 20 years. ‘It can be easily smudged, raises potential data protection issues and may cause difficulties with infection control when you use the same pen but treat different patients,’ he says.
‘There was so much variation’
A lack of standardisation was an additional difficulty, with the studies identifying at least seven different mnemonics used by clinicians during patient handovers. ‘We found there was so much variation, it may cause problems,’ says Dr Fitzpatrick. ‘The cognitive load is really high as you’re dealing with high acuity patients who are extremely unwell.’
To improve handovers, a number of essential components must come together, he says. ‘I look at handovers as part of a system, so you need multiple interventions rather than one, and it’s about how they are linked.’ This includes creating time and having a non-pressured environment, and using a shared mnemonic and documented evidence.
Now the Scottish Ambulance Service has adopted a pre-alert and handover card, co-developed with an emergency department consultant to enhance communication in critical situations. The A6 double-sided, wipe clean, reusable card fits in the thigh pocket of ambulance staff uniforms. ‘Our small study found it was highly acceptable and well used,’ says Dr Fitzpatrick. Results also showed improvements in the delivery of eight out of 12 clinical variables. ‘It’s not the only solution to the problem, but it’s part of it,’ he says.
Lynne Pearce is a health journalist