Clinical handovers are one of the most intricate, frequent, and crucial processes in a hospital. Due to the volume of handovers—estimated at over 300 million handovers per year in the United States, 100 million in England, and more than 40 million in Australia (The Organisation for Economic Co-operation and Development, 2011)—as well as the complex and variable nature of these events, considerable potential for serious consequences exists for patients and health practitioners (Eggins & Slade, 2016b; Garling, 2008; Sabir, Yentis, & Holdcroft, 2006; World Health Organization, 2008). At every handover, there is a possibility of failures, errors, and gaps in communication (Chandler et al., 2015; Pun, Matthiessen, Murray, & Slade, 2015). Research demonstrates that errors in communication within hospitals are one of the primary causes of unexpected adverse events, patient complaints, and malpractice claims (Eastaugh, 2004; Institute of Medicine, 2000; Leonard, Graham, & Bonacum, 2004; Singh et al., 2007; The Joint Commission, 2014). For this reason, clinical handovers are of critical importance in the field of nursing, as hospital nurses are closely involved in the vast majority of care transitions.
Over the past several years, across a range of countries, there have been influential research projects and substantive policy changes related to handovers. As international attention focuses on the need to improve patient safety and dignity, as well as support clinicians, both research and practice have made a major shift toward patient-centered care (also called relationship-centered care). This perspective and set of practices, which is in keeping with human rights principles about the inclusion of patients in their own health care journey, has significant implications for health on a global scale (National Health and Medical Research Council, 2006; Nitzan et al., 2012; World Health Organization, 2014). By actively engaging in health care communication, patients are empowered to understand their condition, follow their treatment plans, and achieve positive health outcomes. In addition, clinicians who enhance their health care communication skills are better able to confidently provide clear, consistent patient-centered care.
Inaccurate or incomplete communication is “a recurring theme among the factors contributing to all incidents” of preventable harm in hospitals (NSW Department of Health, 2006). The communication problems that generate the most serious problems include inaccuracies or omissions in a patient's history, unidentified risks when a patient is transferred to another group of clinicians or location, and failure to escalate care when a patient deteriorates (NSW Department of Health, 2006; Taylor, Wolfe, & Cameron, 2002). These problems may be considered communication gaps or discontinuities that can have a dramatic effect on patient care (Cook, Render, & Woods, 2000).
Clinical handover covers a range of formal and informal communication events (Clark, Squire, Heyme, Mickle, & Petrie, 2009). Until recently, handovers tended to take place in hospital hallways, meeting rooms, nursing stations, and even tearooms away from patients and their family members and carers. Historically, clinicians have spoken about patients in the third person, rarely involving patients, nor asking for input or confirmation of information (Eggins & Slade, 2016b; Eggins & Slade, 2015). Handovers were often “unstructured, informal and error prone,” relying heavily on the clinicians' memories (Bomba & Prakash, 2005, p. 1). Research on clinicians' dialogue reveals an “absence of information about process” (Slade et al., 2008, p. 271). Because many clinicians lack specific training in health care communication, handovers have been highly variable in quality and largely undocumented. This relatively casual approach to handovers has compromised patient safety and dignity (Arora, Johnson, Lovinger, Humphrey, & Meltzer, 2005). The Australian Commission on Safety and Quality in Health Care (ACSQHC) named clinical handovers as one of the five leading contributors to critical incidents—avoidable patient harm (ACSQHC, 2010). ACSQHC recently addressed this patient safety issue, calling for the consistent use of a “timely, relevant and structured clinical handover that supports safe patient care” (ACSQHC, 2012, p. 8).
Transition to Bedside Handovers
Clinical handovers that take place at the bedside and invite the engagement of patients and their family members and carers are referred to as bedside handovers. This form of health care communication offers a unique and important contact point through which clinicians can shape and support positive health outcomes. In bedside handovers, clinicians do not simply disseminate clinical knowledge, but they initiate a two-way communication, thereby encouraging the patient to participate actively in his or her health care (Hobgood, Riviello, Jouriles, & Hamilton, 2002). In addition, bedside handovers create a checks-and-balances system by giving nurses and other clinicians an opportunity to voice their questions or concerns to other health practitioners (Garon, 2012).
Bedside handovers, which represent a patient-centered approach to transitions in clinical responsibility, offer a safer, clearer, more inclusive and comprehensive process for the dissemination of information between clinicians and patients, as well as between clinicians themselves (Bradley, & Mott, 2014; Cummings et al., 2010; Eastaugh, 2004; Ekwall, 2013; Nitzan et al., 2012; Slade et al., 2008). Current research demonstrates that patient-centered communications practices, including beside handovers, can significantly improve patient safety and satisfaction, and appear to contribute to better health trajectories for patients. When clinicians and patients communicate effectively, patients have lower anxiety levels, better compliance with treatment plans, and more positive health outcomes, including a lower likelihood of being rehospitalized within 30 days of discharge (Ekwall, 2013; Jack et al., 2009; Nitzan et al., 2012). Finally, bedside handovers seem to improve clinicians' sense of job satisfaction and may thereby reduce staff turnover.
As a result of the documented advantages of bedside handovers, this practice has become mandatory in several hospitals in Australia (Garling, 2008). Yet, because the practice of mandatory bedside handovers is relatively new, there is not sufficient research on the benefits of moving to this communication practice, nor on the best way to support health practitioners to transition to bedside handovers. In recent research, Eggins and Slade (2015, 2016a) asked clinicians how best to improve health care communication; the clinicians requested the provision of specific training in clinical handovers.
Clinical Training for Bedside Handovers
In addition, pointing out clinicians' interest in receiving bedside handover training, recent research by Eggins and Slade (2015, 2016a) also documented three main types of health care communication problems:
- Contextual (i.e., ensuring that the correct individuals are present at a bedside handover and that communication channels are clear).
- Informational (i.e., seeing that correct information is disseminated and discussed).
- Interactional (i.e., checking that clinicians, patients and caregivers interact to understand the patient journey).
Eggins and Slade (2015, 2016a) demonstrated that at least one of the three types of communication problems emerged in the majority of handovers that were observed. In some instances, there was a confluence of all three types of errors, making the handover communication incomplete, ineffectual, and potentially hazardous to patient safety.
Therefore, Eggins and Slade (2016a) developed two complementary protocols for bedside handovers called CARE (Connect, Ask, Respond, and Empathize) and PPF (Past, Present, Future of the patient journey and condition). These approaches provide both a theoretical and practical foundation for understanding and leading the bedside handover process. One of the key tenets of both the CARE and PPF protocols is the shared care model, through which all nurses have a general awareness and concern for all patients on the ward, not just those they are assigned to assist (Figures 1–2).
The CARE and PPF protocols were used as the basis for a program to provide specialized bedside handover training for a limited group of nurses in an Australian hospital. Following this training, researchers videotaped and evaluated 26 bedside handovers led by nurses who either had or had not experienced the specialized training in beside handovers. This research project is intended to fill an important gap in the health care community's collective understanding of how to define, transition to, and continually support the clinical practice of bedside handovers. In particular, the research questions explored were:
- How effectively are nurses managing bedside handover?
- How can we support nurses to hand over more effectively at the bedside?
Design and Participants
Researchers recruited 26 nurses from a hospital in Canberra, Australia; this institution had recently transitioned to the practice of bedside handovers and had provided bedside handover training to a limited number of nurses. This project was designed to measure the effect of this specific health care communication training for nurses in this hospital. As noted, researchers videotaped 26 actual bedside handovers (one per nurse). Half of the videotaped handovers (n = 13) were conducted by nurses who had recently received the specialized training in bedside handovers that was based on the CARE and PPF protocols. The other half of the videotaped handovers (n = 13) were conducted by nurses without this training. Given that the training had been just prior to the videotaping, there was not a significant long-term interaction between the two groups of nurses. Following the videotaping, two independent expert health care researchers and raters evaluated the 26 videotaped handovers using the Bedside Handover Evaluation Form (BHEF), a tool developed by the research team for this project. The BHEF is based on the CARE and PPF protocols for health care communication. The BHEF evaluates the presence of each of the key behaviors and actions necessary to the successful completion of a bedside handover. Using the BHEF tool, the expert health researchers and raters measured the nurses' behaviors and actions within each of the videotaped handovers.
To date, there is a paucity of research on whether nurses have the full range of health care communication skills required to lead bedside handovers. This project examines the hypothesis that a specific health care communication training program for nurses, particularly a program focused on bedside handovers, is of significant benefit to nurses involved in this important clinical practice.
This study involved the creation, validation, and application of a 27-item evaluation form that was used by expert researchers and raters to evaluate nurses' actions during bedside handovers. The BHEF consists of two sets of questions. The first 24 items are based on the CARE protocol. Each item on the CARE section of the BHEF represents an interpersonal behavior that nurses should enact during a bedside handover although the CARE acronym for Connect, Ask, Respond, and Empathize forms a thematic structure for this approach, the four terms do not represent subscales of the BHEF. Each of the 24 items was analyzed individually as part of the overall BHEF tool.
The three remaining items on the BHEF relate to the information nurses should convey during a best practice handover. The PPF approach offers a chronological perspective on all issues regarding the patient's past medical condition, their present situation and any future concerns, procedures, or treatment plans. There was one item on the BHEF for each of these three areas of information. The BHEF uses a 3-point scale for each item:
- Behavior and information is not evident at all.
- Behavior and information is partial or limited in scope.
- Behavior and information is clearly presented (there is also an N/A response for when the presentation of the behavior is unclear due to visual or auditory limitations in the video recording).
Validity and Reliability
The BHEF (including both the CARE and PPF sections of the form) were validated by four different and independent medical experts who were not involved in the research project in any way. The experts rated each item of the BHEF for validity. For all items, the content validity index (CVI) score was one, which is ideal for that number of expert evaluators. In addition, scale level CVI for the BHEF was calculated for each part of the tool (CARE and PPF) by averaging all the items for each of those sections; this calculation was at the ideal level of .9.
To evaluate the interrater reliability of the BHEF that involved the assessments of two expert raters, researchers used weighted kappa (K) instead of ordinary kappa statistics because of the 3-point scale of the BHEF. Only the items that achieved moderate (K = 0.41 to 0.60), good (K = 0.61 to 0.80), or very good (K = 0.81 to 1.00) levels of interrater reliability were retained for further analysis and presentation. Of the 27 items on the BHEF (24 for CARE and three for PPF), 16 items were included in the analysis due to achieving acceptable interrater reliability. Fourteen of the 24 CARE items achieved the desirable level of interrater reliability. Two of the three PPF items also had acceptable interrater reliability. The Future part of PPF was slightly below the desired level of interrater reliability, but the data are presented in Figure 1 for reference purposes, due to its relevance to the overall PPF protocol.
Ethics approval for this study was obtained from the Ethics Committee of Canberra Hospital. Informed consent was obtained from all participants in the research. Participants also received a verbal explanation about the research project's aims and objectives, as well as their right of withdrawal and confidentiality, before both the distribution of the questionnaires and the videotaping.
First, 26 nurses were recruited to participate in this research in a hospital in Canberra, Australia. Each nurse was filmed for one actual bedside handover. Next, two experienced, independent health researchers were selected as raters for the application of the BHEF tool (these researchers were not in the main research team, nor part of the group involved in instrument validation). The two expert researchers and raters viewed the 26 videotaped bedside handovers, 13 of which were led by nurses who had recently received specific training in bedside handovers, and 13 of which were conducted by nurses who had not received this training. The expert raters were blind to the training status of all nurses depicted in the videotaped handovers.
In analyzing the BHEF (including both the CARE and PPF items), the Fisher's exact test was chosen, due to the small sample size. This test compared the ratings of the two groups of videotaped handovers (i.e., the 13 handovers led by nurses who received bedside handover training and the 13 handovers conducted by nurses without this training). Of the 27 items on the BHEF, 16 items were included in the analysis because they obtained acceptable interrater reliability.
Fisher's exact test showed that for 13 of these 16 items, the ratings for the presence of desired behaviors were significantly higher in the handovers (n = 13) led by nurses with specific bedside handover training, in contrast to handovers (n = 13) led by nurses without training (p ⩽ .05). Figure 1 and Figure 3 display these findings, and the following two sections provide detail on the results.
Behaviors during bedside handover by nurses who had or had not received bedside handover training.
CARE Assessment (13 Items)
Of the 13 items in the CARE section of the BHEF, 11 items showed a strong significant difference between the two groups of nurses. In each case, the optimal behaviors were demonstrated more often by nurses who had received bedside handover training. The following list describes each of the 11 significant differences on the CARE Assessment of the BHEF (in some instances, the number of handovers for each group of nurses is less than 13, due to auditory or visual limitations of the videotaped handover, which necessitated an N/A response). This list of significant results gives both the percentage of nurses and the actual number of nurses (in parentheses) who adequately demonstrated the desired behavior during his or her handover.
- Of the nurses trained in bedside handovers, 100% (n = 11) greeted the patient at the beginning of the handover, whereas 39% (n = 5) of the nurses without training did this (p ⩽ .01).
- Eighty-five percent (n = 11) of the trained nurses explained why the nursing team was present at the bedside; 15% (n = 2) of the nontrained nurses addressed this issue (p ⩽ .01).
- In the group of nurses who received bedside handover training, 100% (n = 10) made eye contact with the patient and 100% (n = 12) had a positive facial expression during the handover; only 36% (n = 4) of the other nurses made eye contact and 46% had a positive facial expression (p ⩽ .01).
- Sixty-nine percent (n = 9) of the nurses with handover training asked patients direct questions; none (n = 0) of the other nurses did so (p ⩽ .001).
- Sixty-two percent (n = 8) of the trained nurses asked patients for clarification of all medical information discussed and 62% (n = 8) asked for confirmation of this information; none of the untrained nurses asked for clarification or confirmation (p ⩽ .01).
- One hundred percent (n = 13) of the trained nurses listened to the patient and reacted to his or her comments or questions; only 8% (n = 1) of the untrained nurses did this (p ⩽ .001).
- One hundred percent (n = 10) of the trained nurses responded to comments or queries by colleagues on the nursing team; 67% (n = 8) of the untrained nurses did this (p ⩽ .001).
- Among the nurses trained in bedside handovers, 100% (n = 13) appeared to act respectfully and sensitively toward the patient, whereas none (n = 0) of the other nurses appeared to do this (p ⩽ .001).
PPF Assessment (Three Items)
The PPF section of the BHEF evaluates the communication of key medical information about the patient in a chronological format. Our results on the PPF section show significant differences on two of the three items. Results for the Past item were not significantly different between the two groups of nurses. The Future item showed a statistically significant difference, but it is reported here for reference purposes only because this item did not achieve acceptable interrater reliability. As seen in Figure 1, results in the PPF section are reported in more detail than for the CARE items, due to the complexity of information involved in rating this item and the importance of moderate differences in this area. The one main significant difference was on the “present” item. This item is of clinical importance due to its relation to patient safety.
Nurses with training in bedside handovers provided full information about the patient's current condition in 100% of the videotaped handovers. Nurses without this training gave complete information in just 38% of the handovers; the nurses without training provided partial information in the other 62% of handovers (p ⩽ .002).
In summary, the results of this study show a striking difference between the handovers conducted by nurses who received specific bedside handover training and nurses who did not. The nurses who participated in training were subsequently far more likely to elicit and articulate more complete information about their patient's medical journey, interact with patients to a greater extent, and lead a more inclusive handover that invited participation from patients, carers, and other clinicians. It appears that clinical practice is greatly enhanced by professional development in bedside handovers. Given the crucial importance of handovers, specific training in bedside handovers seems to be a powerful tool for improving clinical practice in hospitals.
Current research shows that well-executed bedside handovers are associated with improved levels of patient safety, patient satisfaction, and clinician satisfaction (Chaboyer et al., 2009; Kassean & Jagoo, 2005; McMurray, Chaboyer, Wallis, Johnson, & Gehrke, 2011; Thompson et al., 2011; Watkins, 1997; Webster, 1999). The results of this research indicated that hospitals may make notable improvements in each of these areas if they provide specific health care communication training for nurses that focuses on bedside handovers. This research demonstrates that nurses who receive this training are more likely to conduct an excellent bedside handover. For most of the clinical behaviors measured by the BHEF, 100% of the nurses with training demonstrated the relevant skill during the handover.
Conversely, this research suggests that bedside handovers led by nurses without training do not consistently demonstrate optimal actions. In approximately half of the bedside handovers conducted by nurses without specific bedside handover training, there appeared to be no clear transfer of responsibility and accountability for the patient's ongoing care, although this transfer is the defining rationale for a clinical handover. Information was missing and clinical and patient interpersonal contact was inadequate in the majority of handovers.
The results of this research project show the need for specific bedside handover training for nurses. The training nurses received prior to this research project consisted of only one 2-hour session duration, yet it appeared to have a significant effect on subsequent clinical practice.
In short, this research demonstrates that nurses without bedside handover training may not be performing well in this area of clinical practice. However, with targeted, concise training, nurses who work to develop these skills can usually apply them in clinical practice to ensure a more transparent, complete, inclusive, and respectful bedside these 13 handovers.
The research team acknowledges the relatively small sample size of 26 (13 handovers per condition). This limitation is due to the practical difficulties of videotaping bedside handovers on a hospital ward. There are issues related to auditory and visual clarity of the recordings, obtaining participant consent and transferring, cataloguing, and storing large data files. Nonetheless, these 26 videotaped handovers still offer meaningful insight into both the problems with current bedside handovers and the benefits that specific training can bring to this clinical practice. It is important to note that having a small sample size generally lessons the power of statistical tests, sometimes resulting in the incorrect acceptance of the null hypothesis. However, this study showed strong, statistically significant results, thereby rejecting the null hypothesis. This means that the effect of the intervention (i.e., beside handover training for nurses) was large enough to be detected by tests with relatively low power.
The research team is in the process of collaborating with additional clinical groups (doctors and nurse practitioners) in other countries. In the future, the research scope will be expanded to include other locations, as well as the views of patients themselves and their families and caregivers; thus, the data set will be more holistic.
Implications for Nursing Education
This research project highlights the benefits of specific bedside handover training for nurses. This work also shows that, in the absence of specific training in bedside handovers, nurses may lack the skills to adequately engage in bedside handovers. Therefore, this research project provides striking evidence for the benefit of specific bedside handover training for nurses and, potentially, other clinicians and health care workers.
Although bedside handovers are now mandatory in some hospitals in Australia, there is currently not sufficient training support for these recommended policy changes. By offering clinicians targeted communication training—training that is grounded in the reality of complex hospital interactions—clinicians are likely to become more confident, efficient, and effective in conducting bedside handovers. In turn, hospitals that provide this training will be more likely to realize the significant gains in patient safety, satisfaction, and overall health outcomes that these new clinical practices may bring. This research points to a clear need for professional training through an approach similar to the CARE and PPF protocols to improve the quality of nursing care via bedside handovers. Ultimately, this change toward excellent communication through bedside handovers will enhance the experience of health care for both patients and clinicians in Australia and overseas.
Bedside handovers will represent a cost-effective, comprehensive, patient-centered communication strategy that seems to raise the levels of patient safety and satisfaction, as well as improve patient outcomes overall. In addition, bedside handovers serve to enhance the professional environment for clinicians. This research highlights the need for specific bedside handover training for nurses. Overall, the researchers involved in this project advocate for the implementation of a health care communication training program, such as the CARE and PPF protocols. This research strongly suggests that specific health care communication training can have a significant, immediate, and cost-effective benefit on the quality of care transitions for patients.
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