Improving the efficiency of patient handover

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IMPROVING THE EFFICIENCY OF PATIENT HANDOVER JANE CURRIE outlines the results of a study into A&E handovers

Jane Currie, BSc (Hons), RGN, was staff nurse, Selly Oak Hospital, Birmingham at the

NEIL O’CONNOR

time of writing this article

This article has been subjected to double blind peer review

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andover is an important nursing ritual, essential for continuity of care (Kennedy 1999), and as nurses we should be aiming to improve the efficiency of handover in the environment we work in. This piece of research was invited by the A&E clinical manager at Selly Oak Hospital, Birmingham, following the author’s audit on handover on a surgical ward (Currie 2000). The aim of the research was to identify which topics of handover should receive the highest priority when working in an A&E environment. At the time of writing there appeared to be no available research on handover in the emergency department environment. However, there is a wealth of literature on nursing handover on wards. Topics ranging from its contents (Hesse 1983), its length (Matthews 1986, Sherlock 1995, Thurgood 1995), the methods of handover, including bedside (McMahon 1990, Howell 1994) tape recorded (Mosher and Bontomasi 1996) and nonverbal (Kennedy 1999) to patient confidentiality during handover are described (Howell 1994). The literature shares one common feature; being that handover influences the delivery of care for the following shift (Thurgood 1995). Hesse (1983) argued that a successful handover should be guided by nursing and medical documentation and it should include the patient’s diagnosis, vital signs, diagnostic tests and restrictions. Including these topics may ensure that handover is accurate. Modern nursing is extremely fluid, there is a high turnover of both staff and patients so the accuracy of handover becomes ever more important.

RESEARCH DESIGN To obtain a large amount of information in a swift time frame, the author selected a questionnaire design (Table 4). The questionnaire design was based on the ‘Content checklist’, which was used in the previous audit (Currie 2000), this encompassed the topics listed by Hesse (1983). The research assistant verified the questionnaire. The study was piloted on the emergency admissions assessment unit, and this acute environment made an excellent training ground for this research. The pilot study highlighted two areas requiring modification. First, the researcher added one topic to the questionnaire. Second, when analysing the data from question 13, many nurses gave more than one response. The method of analysis for this data was modified so that the data was listed in a table, instead of being expressed as a percentage of the sample group. Each staff nurse working in A&E at the time of the study was posted a copy of the questionnaire, a cover letter and an SAE. After three weeks the study was closed. DATA ANALYSIS AND RESULTS Forty six questionnaires were posted, 28 were returned. The responses to each question, 1 to 12 were added together and expressed as percentages in Table 1. The responses to question 13 were formulated in Table 2. The responses to question 14 were added together and expressed as a percentage in a pie chart. > Information missed included patients missed out, poor nurse communication, handover not from named nurse.

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> Distraction included noise, interruptions, and inattention of staff. > Lack of confidentiality included no privacy at nurse’s station, relatives in close proximity. > No handover at start of shift refers to commencing an intermediate shift e.g. 10-1800hrs, 18-0200hrs and not receiving a handover at start of shift. Question 14 – 4 non-valid responses DISCUSSION The respondents gave these six topics the highest priority (see Table 3): > Patient’s reason for admission > Treatment patient has received > Patient’s name and age > Present restrictions on the patient > Plan of care for the patient > Patient’s relevant past medical history. Working in an emergency clinical setting everything is prioritised, including the information given during nursing handover when information needs to be passed on as quickly and efficiently as possible. The topic areas chosen above fulfil the information quota advocated by Hesse (1983) lending it to a successful handover guideline. It is striking that the patient’s social details are not prioritised, especially as social aspects are often the cause of delays in discharge. Since verbal handover is supported by written documentation, nurses would have to look there for the patient’s social details if they were not handed over verbally. Including salient information regarding patients’ social circumstances in verbal handover may be beneficial in improving the rate of discharge. Information missed was cited as one of the main problem areas; the omission of patient’s details could seriously endanger care by encouraging errors. Richards’ (1988) identified incongruences between inter-shift reports and patients’ conditions, and felt this highlighted a lack of standard setting for verbal handover. There are legal implications for this, in a climate of increasing workload and pressure of time, handover needs to be accurate and concise (Thurgood 1995). One respondent described how handovers given by someone other than the named nurse led to information being missed. Ensuring that handover has a consistent structure and is delivered by the patient’s named nurse could overcome this problem.

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Table 1. Order of priority assigned to handover topics Topic

Total score as per cent (%)

Reason for admission

99%

Treatments patient has received

94%

Patient’s name and age

93%

Present restrictions on patient

93%

Plan of care for patient

90%

Past medical history

88%

Patient’s vital signs

87%

When patient last ate and drank

77%

Patient’s next of kin

70%

Whom is accompanying patient

68%

Patient’s social circumstances

67%

Patient’s living arrangements

66%

Table 2. Problem areas of handover Topic nurses expressed

Number of nurses expressed by

Information missed*

14

Distractions*

12

Lack of Confidentiality*

7

Irrelevant Information

2

Inaccurate Information

2

Handover directed to sister rather than to all staff

2

Too detailed

1

Difficult to put a face to a name

1

No handover at start of shift*

1

Delay in start of handover

1

Delivering handover intimidating

1

No guidelines for handover

1

Twelve respondents described ‘distractions’ as a problem area. At the time of study handover was delivered at the nurses station situated on the ‘Majors’ area of the department. The regular distractions of the telephone, patients’ relatives approaching the nurses, doctors and nurses interrupting handover altogether, increased the length of handover and reduced the attention span of those listening and those delivering handover.

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Fig 1. Handover preferred at the bedside or at the nurses’ station

nurses'

bedside

both

nurses' stationbe reduced to improve Distractions must station nurses’ focus, and then the time donated to handover would be more valuable. In order to comply with the UKCC neither guidelines on confidentiality nurses must attempt to ensure confidentiality is maintained during handover. This presents both many challenges. Nurses can ensure that relatives are not in close proximity, and handover can be spoken clearly and directly bedside to the members of the next shift avoiding loudneither speech. When handing over at the bedside, nurses must ensure they enter the

Table 3. The six topics assigned highest priority Patient’s reason for admission Treatment patient has received Patient’s name and age Present restrictions on the patient Plan of care for the patient Patient’s relevant past medical history

cubicle and avoid handing over outside where others may be listening. HANDOVER AT STATION OR BEDSIDE? The nurses station was the most popular venue as it provided confidentiality and one could receive all information at once, reducing the length of handover. Twenty nine per cent of respondents preferred bedside handover because it enables one to ‘put a face to a name and gave the opportunity to begin patient assessment and introduce staff to patients in accordance with the philosophy of patient centred care (McMahon 1990). One respondent felt that patients are sometimes intimidated by bedside handover, Cahill’s (1998) study of bedside handover supports this observation, nurses must use their skills ensuring that patients are given the opportunity to participate and ask questions during handover to reduce their anxiety. Twenty five per cent of respondents felt that handover was most effective when the nurses’ station was used to hand over the

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essential patient information and was followed by a bed to bed handover. Although this method holds many advantages, it is time consuming, and this may be a costly use of nursing time during peak periods within the department. One respondent felt that the sister’s office was the most efficient venue as it provided a confidential environment and reduced distractions. However, this venue would require the absence of several nurses, as well as the patient’s documentation from the department during peak times. RECOMMENDATIONS To set a standard for verbal handover, the details in Table 5 should be consistently included in each nursing handover. In order to improve the quality, each handover should be CUBAN, that is: > Confidential > Uninterrupted > Brief > Accurate > Named nurse Using a clinical guideline to frame handover may improve the consistency, accuracy and focus of each handover, which would be reflected in an improvement in the quality of nursing care delivered by the next shift. The author recommends this guideline is implemented and then evaluated by audit to establish its strengths and weaknesses. The guideline may also be used to teach nursing students the information which will be required in handovers they deliver. CONCLUSION The research has been successful in establishing the priority that nurses in the emergency environment assign to topics of handover. The respondents raised many problem areas of handover which need to be resolved. The author has proposed a clinical guideline for handover which, if implemented, could reduce the omission of detail and distractions currently associated with handover, giving it greater focus and accuracy. Echoing the sentiments of Hesse (1983), this clinical guideline for handover aims to improve nursing care by improving handover. Acknowledgements I would like to thank staff nurse Houlihan for her assistance and all staff whom participated in the study.

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Table 4. Questions to identify the priority nurses attach to the contents of handover Table 4 – questions to identify the priority nurses attach to the contents of handover. Questions 1-12. On a scale of 1 to 10 (where 1 is not important and 10 is extremely important) please indicate the importance of including each of the following topics in each nursing handover. 1. The patient’s name and age? 2. The patient’s reason for attendance? 3. The patient’s relevant past medical history and medications? 4. The patient’s vital signs? 5. The patient’s next of kin? 6. The patient’s living arrangements? 7. Whom is accompanying the patient? 8. The main treatments the patient has received? 9. When the patient last ate and drank? 10. The plan of care for the patient? 11. Present restrictions on the patient (such as NBM, bed rest)? 12. Patient’s present social circumstances (such as unemployed, sole carer for a relative/friend) 13. What are the worst aspects of the handovers delivered and received in your clinical are at the present time? 14. Do you prefer bed to bed handovers or handover at the nurse’s station? Why?

References Cahill J (1998) Patient’s Perceptions of Bedside Handovers. Journal of Clinical Nursing 7, 351-359. Currie J (2000) Audit of Nursing Handover. Nursing Times 96, 42, 44. Hesse G (1983) A Better shift report means better nursing care. Nursing 13, 2, 65. Howell M (1994) Confidentiality during staff reports at the bedside. Nursing Times 90, 34, 44-45. Kennedy J (1999) An evaluation of non-verbal handover. Professional Nurse 14, 391-394. Matthews A (1986) Patient centred handovers. Nursing Times 82, 24, 47-48.

Table 5. Clinical guidelines for nursing handover Name and age Reason for attendance (Vital signs and past medical history if significant) Treatments patient has received Restrictions on patient Plan of care (Social circumstances if significant)

McMahon R (1990) What are we saying? Nursing Times 86, 30, 38-41. Mosher C, Bontomasi R (1996) How to Improve your Shift Report. Annual Journal of Nursing 96, 8, 32-34. Richard J (1988) Congruence between Intershift reports and patients’ actual conditions. New Scholarship 20, 1, 4-6. Sherlock C (1995) The patient handover: A study of its Form, Function and Efficiency. Nursing Standard 9, 52, 35-36. Thurgood G (1995) Verbal handover reports: What skills are needed? British Journal of Nursing 4, 12, 720-722.

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