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QUANTITATIVE
(e.g. Patterson & Wears 2010). These authors argue that, identified three categories of processes: information transfer,
although standardization certainly has merit, handovers shared understanding and working atmosphere, to predict
provide an important ‘audit-point’ essential for potential perceived handover quality. However, most of these studies
recovery from failure. So it might be constructive to inte- relied on the subjective perceptions of the healthcare staff in
grate elements of resilience into the handover practice (e.g. assessing the quality of the handover.
Jeffcott et al. 2009, Hill & Nyce 2010, Patterson & Wears The final category – outcome measures – usually assesses
2010, Hilligoss & Cohen 2011). At the simplest level, staff’s perceptions of or satisfaction with the handover
handover carries opportunities for correcting errors by such (Borowitz et al. 2008, O’Connell et al. 2008, Chaboyer
actions as running a safety scan of functioning equipment, et al. 2010, Farhan et al. 2012, Klim et al. 2013), provid-
double-checking a medication dosage and/or a lab value ers’ confidence (Payne et al. 2012) or perceived near- miss
(Hilligoss & Cohen 2011). Beyond simple error correction, on-call (e.g. Payne et al. 2012). To date, most studies have
the resilience perspective suggests that handovers might relied on subjective outcome measures of handovers and
convey opportunities to detect and ‘bounce back’ from only few have attempted to link handover content or pro-
unexpected events through systematic application of intui- cess characteristics with objective outcome measures (except
tion, anticipation and foresight skills (Weick & Sutcliffe Arora et al. 2005, Borowitz et al. 2008, Thomas et al.
2007, Jeffcott et al. 2009). Communication during hand- 2013). Handover outcome measures could also benefit from
over can also afford new perspectives on a patient’s situa- measurement of objective criteria, such as treatment errors
tion through the outgoing team’s refreshed attention to him in the following shift (Riesenberg et al. 2010, Manser &
or her while preparing for the handover, or of the incoming Foster 2011). Human errors pertain to unintentional
team’s ‘fresh perspective and rested mind’ (Patterson et al. actions; deviation from expectations, namely actions that
2007, Hilligoss & Cohen 2011). took the task or system beyond its acceptable limits; or
undesirable actions, namely deviation from a set of rules or
Assessing handover quality an external observer (Reason 1990). Although such devia-
Previous research has typically assessed handover quality by tions in themselves do not necessarily produce adverse
three types of measures: its content, process or outcomes consequences (i.e. patient’s harm) – if they are minor or
(Cheung et al. 2010, Manser & Foster 2011). The first cat- detected and put right early, they create conditions that
egory – handover content – has been mostly descriptive, make such consequences more likely to occur (Fogarty &
concentrating on the completeness and accuracy of informa- McKeon 2006). In sum, an accurate understanding of how
tion (Arora et al. 2005, Berkenstadt et al. 2008, Horwitz an effective handover affects patient’s safety and reduces
et al. 2009a,b). These studies typically showed verbal hand- errors is still lacking.
over to be incomplete compared with the information avail-
able in the patient’s record (Lamond 2000, Arora et al.
The study
2007) or compared with a pre-defined handover protocol
(Catchpole et al. 2007). Moreover, this line of research
Aim
ignores the dispute over the definition of which items
should be included in such a list (Riesenberg et al. 2010, The main aim of this study was to narrow this gap in
Manser & Foster 2011) and whether assessing a small num- research by examining the relation between the strategies
ber of highly relevant items in the handover may be more nurses employ during handover and the number and types
effective than looking at a larger number of less relevant of treatment errors in patient care in the following shift.
items (Philibert 2009).
The second category – the handover process–assesses its
Design
environmental aspects (e.g. interruptions, workload) or its
behavioural aspects (e.g. preparation for the handover, using The study took a mixed-method prospective approach,
written memos, shared decision-making and verbal face-to- combining observations, surveys and pooling data from
face reports) (Apker et al. 2010, Chaboyer et al. 2010, patients’ charts for data collection.
Manser et al. 2010, Manser & Foster 2011). Research in
this area exceeds information transmission, to identify
Sample and procedure
through surveys or structured observations the processes
vital for the quality of the handover. For example, Manser Data were collected during 2012–2013. Two hundred
et al. (2010) developed a structured observation sheet and handovers were sampled as follows: Before the handover,
five patients were randomly selected for inclusion in the observed in 100 per cent of the handovers, hence were
study, based on a list of all patients hospitalized in the analysed no further. One strategy (‘outgoing has knowledge
ward: three ‘complex’ patients with Charlson Comorbidity about prior shift activities’) was also customary in all hand-
Index (CCI) (CCI ≥ 3) and two ‘simple cases’ with overs, so it was replaced by ‘departing are present at physi-
(CCI < 2). During the handover, transfer of information on cians’ rounds.’ Another strategy (‘read back to ensure that
these patients was observed and demographical data of information was accurately received’), only rarely observed
incoming and outgoing nurses involved in the handover and by Patterson et al. (2005), was not observed at all in our
context information, were collected. Near the end of the sample. A strategy that was prevalent to some degree in
shift following the handover a research assistant, who was our sample (‘incoming checks medical equipment’) was
a senior nurse (near completion of his MA degree) and an added. Observers were instructed to mark ‘yes’ when the
expert in risk management, extracted from the patient’s strategy was observed and ‘no’ when it was not. Percent-
chart data that might indicate errors. ages using each strategy are presented in Table 1.
The study was conducted in five nursing internal wards.
Hospital policy was to place patients evenly among wards,
Ethical consideration
so that wards were about the same in their mix of illnesses
and complexities. The five wards applied a face-to-face, The study was approved by the Medical Ethical Review
bedside, verbal handover process three times a day. No Board of the medical centre.
standardized template was in use when the study was con-
ducted. Each outgoing nurse handed the information about
Rigor
the patients under her or his care to her or his incoming
counterpart (approximately, six patients per nurse). Several steps were taken to validate the observation sheet.
First, the tool was reviewed by five nurse specialists for
content validity and slight changes in the wording of the
Data collection
strategies were made. Secondly, a pilot study of 30 hand-
Outcome measures overs was conducted to test the observation sheet. Observ-
The outcome measure in this study was treatment errors, ers noted that the strategies were clear, easy to measure
defined here as ‘deviations from prescribed care’ as found and representative of nursing handover. Two graduate stu-
from a check of the patient’s chart in the shift after hand- dents, nurses by profession, participated as observers. The
over. It was first checked for any care order given before ward’s nurses perceived their presence as natural, which
the handover (e.g. starting new medication, terminating might prevent bias, yet the observers’ objectivity could be
medication usage, screening, lab tests, change in nutrition, relied on and they were familiar with the best practices of
physiotherapy). Based on Warrick et al. (2011), three handover strategies. To ensure inter-rater reliability and the
measures were then extracted from the patient’s chart on a observations’ validity the observers received 12 hours of
dichotomous scale (1 = yes; 0 = no): (1) Late/non-executed extensive training. This covered: (a) observation techniques
care order – namely whether the nursing/medical order had in research; (b) a thorough study of the handover process;
or had not been performed as prescribed and on time; (2) and (c) participation in periodic meetings during the
Missing documentation – in the patients’ files on the execu- observation period when categorization dilemmas were dis-
tion of care orders; (3) Dosage discrepancy – as against the cussed and resolved by the group consensus technique
medication order, namely the nurse had administered the (Kappa = 088), indicating a good inter-rater reliability.
wrong dosage. The total number of errors in the three
measures was then calculated.
Data analysis
(1) Face-to-face verbal update with interactive 12% 33% 514 0037 9% 24% 388 0046 26% 40% 166 0376
questioning (55%)
(2) Update from practitioners other than the 9% 48% 1407 0008 7% 32% 893 0007 26% 35% 084 0538
outgoing (57%)
(3) Limit interruptions during update (77%) 5% 26% 515 0043 14% 46% 777 0005 19% 43% 440 0042
(4) Topics initiated by incoming and outgoing 25% 54% 531 0028 25% 51% 310 0045 57% 42% 166 0658
(51%)
(5) Include outgoing team’s stance on care plans 14% 24% 128 0835 24% 47% 370 0042 34% 32% 018 0439
(70%)
(6) Outgoing writes summary prior to handover 11% 24% 091 0587 33% 42% 027 0584 11% 18% 029 0328
(9%)
(7) Outgoing participated in medical rounds 0% 34% 1825 0001 0% 24% 1301 0007 29% 33% 025 0743
(67%)
(8) Incoming check medical equipment (35%) 0% 35% 659 0032 12% 34% 382 0038 0% 25% 414 0041
This approach was suitable because the variance of our before the meal or not at all. In 33% of the handovers
dependent variable exceeded its mean, indicating over dis- documentation was absent from the files, for example, exe-
persion in the data (Long 1997). The control variables cution of an order for a lab test, change in diet, or physio-
(department, nurse’s tenure, complexity of the patient’s therapy given by the physician.
condition) were entered in step 1. The main effect terms of Table 1 presents the percentages of treatment deviations
the handover strategies were entered in step 2. (as documented in the shift following handovers) in hand-
overs that observed strategies compared with handovers
that did not. The table shows that ‘limit interruptions dur-
Results
ing update’ was observed in 77% of the handovers; and
‘incoming check of medical equipment’ in 35% of the
Characteristics of the sample
handovers. Significantly fewer dosage discrepancies, late- or
Two hundred bedside handovers were observed in five non-executed care orders and documentation errors were
medical wards. Mean handover time was 7345 seconds (SD found in handovers that applied these given strategies than
1816) and 5056 seconds (SD 1376) for complex and non- in handovers that did not. Next, ‘face-to-face verbal update
complex patients, respectively. Ninety per cent of the with interactive questioning’ was observed in 55% of the
incoming nurses and 80% of the outgoing nurses were handovers; ‘update from practitioners other than outgoing’
women. Ages of the incoming nurses were 24-58 years was applied in 57% of the handovers; ‘topics initiated by
(mean 39, SD 1044) and of the outgoing nurses 25– incoming and outgoing’ in 51%; and ‘outgoing participated
60 years (mean 44, SD 1088). Average unit tenure of the in medical rounds’ was applied in 67% of the handovers.
incoming nurses was 15 years (SD 1149) and of the outgo- In all these cases, significantly fewer dosage discrepancies
ing nurses 19 years (SD 1190). and late- or non-executed care orders were found in hand-
overs that applied the given strategy than in handovers that
did not. However, no statistically significant differences in
Treatment deviations
missing documentation were found between handovers that
Documentation drawn from the patient’s chart in the shift did and did not use the strategy. The strategy of ‘including
following handover, showed dosage discrepancies in 23% outgoing team’s stance on care plans’ was used in 70% of
of the handovers; an example is half of a prescribed dosage the handover; significantly fewer late- or non-executed care
being provided. Delayed or not-executed care orders were orders were found in handovers that applied the given strat-
found in 52% of the handovers, for example, a prescribed egy than in handovers that did not. Finally, the strategy of
antibiotic that had to be taken after the meal was given ‘outgoing written summary prior to handover’, used only in
9% of the observed handovers, was not significantly related ‘bounce back’ from errors, with obvious positive conse-
to treatment deviations of any kind. quences for patient’s safety (Jeffcott et al. 2009, Cohen &
The results of the negative binomial regression analysis Hilligoss 2010, Hill & Nyce 2010). The findings demon-
for predicting number of treatment errors, from handover strated, in accordance with Reason’s (2004) three-bucket
strategies and control variables, are presented in Table 2. model, that a nursing handover provides an opening for
Model 1 includes only the control variables, while Model frontline nurses to prevent errors and unsafe practice, if
2 adds the explanatory variables of handover strategies. It they adopt more risk-aware and ‘error-wise’ handover strat-
significantly improves model fit over Model 1: the likeli- egies. Our findings thus contribute to current handover
hood ratio test statistic of improvement in model fit is research in several aspects.
1057, significant at P < 001. As for the control variables, First, in line with previous research, our findings show
a significant difference in the treatment errors among that a nursing handover is a point of vulnerability. On aver-
wards was found (B = 0606, P < 005). However, the age, in nearly one-fifth of any handover, some sort of devia-
departing nurse’s tenure, and the patient’s complexity tion from ‘accurate dosage’ of medication occurred; in
score, was not linked to the number of treatment errors nearly one-third a care order was executed late or not at
(P > 005). all; and in nearly half of the handovers documentation was
Among the handover strategies, ‘face-to-face verbal partially missing. As mentioned earlier, although these
update with interactive questioning’ (B = 0842, treatment errors in themselves do not necessarily produce
P < 005); ‘update from practitioners other than the outgo- adverse consequences (i.e. patient’s harm), they create con-
ing’ (b = 0721, P < 001); ‘topics initiated by incoming ditions that make such consequences more likely (Fogarty
as well as outgoing’ (b = 0801, P < 001); ‘include out- & McKeon 2006). Our evidence thus augments previous
going team’s stance on care plans’ (b = 0742, P < 001); findings reporting some sort of distorted communication,
and ‘outgoing writes summary prior to handover’ ranging from 198% (Thomas et al. 2013)–30% (Arora
(b = 0432, P < 005) were significantly and negatively et al. 2005) and 31% (Borowitz et al. 2008), depending on
linked to the number of treatment errors. No significant definition, type and assessment of the errors, as a result of
links were found between the remaining three strategies poor handover strategies.
and the number of treatment errors. Second, handover strategies previously adopted from high
reliability organizations (HRO) (Patterson et al. 2005, Phili-
bert 2009) were shown to vary substantially in their rate of
Discussion
use. Some were rarely used (e.g. ‘outgoing written summary
This study took a resilience perspective, arguing that prior to handover’, ‘incoming check of medical equip-
although a nursing handover is certainly a vulnerable point ment’); others were used moderately (e.g. ‘topics initiated
of care it also presents opportunities to identify, correct and by incoming and outgoing’, ‘face-to-face verbal update with
Table 2 Negative binomial regression analysis for predicting number of treatment errors (N = 200).
Model 1: controls Model 2: direct effects
Variables B SE B SE
interactive questioning’, ‘updates from practitioners others files in the shift following the handover. One possible
than the outgoing nurse’); while still others strategies were explanation for these findings is that the emphasis on the
used regularly. These findings are similar to previous find- active role of both the incoming and the outgoing teams
ings on HRO handover strategies of residents and nurses facilitates safety through the development of team situa-
(Patterson et al. 2005, Philibert 2009). tional awareness (Patterson et al. 2005, Hilligoss & Cohen
But perhaps our most interesting finding concerns the 2011). Situational awareness refers to the departing and
links found between the handover strategies nurses receiving nursing teams maintaining the ‘big picture’ and
employed and treatment errors. This result reflects the thinking ahead to plan and discuss contingencies. This
recent dual focus of safety science on both system design ongoing dialogue, which keeps members of the team up-to-
and system resilience (Leape & Berwick 2005, Thomas date with what is happening and how they will respond if
et al. 2013). System design refers to standardized the situation changes, is a key factor in patient safety
approaches, aiming to simplify and streamline clinical (Leonard et al. 2004, Patterson et al. 2005). Indeed, Boro-
handover, providing nurses with a firm grasp of what is to witz et al. (2008) found that residents commented on the
be conveyed during handover and how it is to be done importance of including contingency plans, and the ratio-
(Spooner et al. 2013). Two of our strategies – ‘limit inter- nale for the plan of care during handovers, so that if
ruptions during update and outgoing writes summary prior changes are needed during an on-call shift there is a clear
to handover’ – could be viewed as such an approach. Only context for how best to make those changes.
the latter was linked to the number of treatment errors. Two additional strategies–‘update from others than the
However, as our findings demonstrate, flexibility and resil- incomings and outgoing participated in medical rounds’ are
ience elements exercised alongside standardized procedures embedded in a team interaction perspective on handovers
will help ensure patient safety and the overall quality of the (Patterson & Wears 2010). This perspective draws from
handover. team research to posit that considering multiple viewpoints
Three of the observed strategies concern substituting the during the handover (e.g. by the head nurse, the patient,
info-centric approach with a more user-centric approach, the caring physician) in evaluating the patient’s condition
emphasizing not only the departing nurse’s responsibility can have several benefits (Richard et al. 2004, Singh &
for handing over complete information but also the receiv- Point 2006, Shore et al. 2009). First, diverse views reflect
ing nurse’s needs for clarification, discussion and appraisal qualitative differences that equip teams with a broader
of the patient’s current condition (Scott et al. 2012). Our range of approaches to patient evaluation. Different per-
findings indicate that the strategies of ‘face-to-face verbal spectives and knowledge form the core of the ‘value-in-
update with interactive questioning’, ‘topics initiated by diversity’ hypothesis (McLeod et al. 1996) – a value that is
incoming as well as outgoing’ and ‘include outgoing team’s deemed especially advantageous for developing a thorough
stance on care plans’ were linked to decreased treat- understanding of the patient’s condition and maintaining
ment errors. Providing more than facts, then, seems to be patient safety (Weller et al. 2014). Second, exposure to
essential in maintaining patient safety and continuity of diverse opinions also decreases the likelihood of cognitive
care! Apparently, communicating not only retrospective bias that might occur when the incoming nurse inappropri-
objective information on patient’s background, physical ately applies default assumptions of the outgoing nurse’s
state and procedures already performed, but also on care approach (Nemeth & Owens 1996). Third and closely
options, predictions of the patient’s prognosis and anticipa- related to the last two benefits, diverse perspectives on the
tions of ‘what could possibly go wrong,’ was linked to patient’s situation can contribute identifying, correcting or
fewer errors. This type of information is often not included ‘bouncing back’ from errors (Patterson et al. 2007, Hilli-
in handovers and is increasingly difficult to find in the med- goss & Cohen 2011). Our findings accordingly indicate that
ical records (Borowitz et al. 2008, Philibert 2009, Manser the strategy update from others than outgoing nurse was
et al. 2013). These findings are consistent with previous linked to decreased treatment errors. This finding is in line
research, demonstrating that the benefits of face-to-face ver- with previous studies demonstrating that updating by more
bal handover are more fully reaped when nurses perceive it informants such as the head nurse and other caregivers
as an opportunity for interactive discussion (e.g. Patterson (Borowitz et al. 2008, Hilligoss & Cohen 2011, Scott et al.
et al. 2005, Scott et al. 2012, Manser et al. 2013). Still, 2012) and patient involvement (e.g. Davis et al. 2007,
our findings elaborated previous findings by showing links Drach-Zahavy & Shilman 2015), may enhance the nurse’s
not only with subjective appraisal of the handover’s quality familiarity with the patient, facilitate the development of a
but also with fewer errors as indicated from the patients’ more complex view of his or her condition and contribute
to improving patient safety. Surprisingly, no link was found strategies and fewer treatment deviations are both influ-
between the strategy of ‘outgoing participated in medical enced by common organizational factors such as safety
rounds’ and fewer errors. Perhaps the mere participation of climate (Zohar 2002); these impacts should be examined
the nurse in the medical round does not guarantee that she in future studies.
will provide novel information on the patient during the
handover.
Practical implications
Our findings could not support the importance of assur-
ing the integrity of the medical technological devices, such Our study presents opportunities for interventions aimed to
as actual checking of the mechanical ventilators, syringes improve communication during handover. The findings,
and monitoring system alarms, checking that infusion which support the association between specific handover
orders were consistent with the medications infused into strategies, errors and handover quality, suggest the integra-
the patient and reviewing medication charts. Perhaps this is tion of flexibility alongside standardized procedures. First,
because this strategy was rarely observed. Several authors to ensure that incoming nurses play a more active role in
have emphasized the gap between the rare use of these handovers, training interventions should be developed
strategies and their benefit to handover quality and reduced aimed at teaching incoming nurses strategies to speak up
errors, advocating teaching nurses to apply these strategies and make sure that they receive the information they need
(Spooner et al. 2013, Thomas et al. 2013). For example, (Weinger et al. 2010, Manser et al. 2013). A more radical
Perren et al. found that about two-thirds of ICU-to-ward option might be to structure handovers differently, by
handover reports contained at least one error that was dis- allowing the incoming nurse to lead the handover through
covered by nurses trained to check the medical technologi- a three-stage process: reading the written report, receiving
cal devices (Perren et al. 2008). an impression of the patient and asking the outgoing nurse
for additional information. Second, the finding that inclu-
sion of the team’s stance on care plans is important is not
Limitations and suggestions for further research
new, but has been previously indicated in several standard-
This study has several limitations. The first limitation ized handover formats such as SBAR, albeit with limited
pertains to the limited sample size of 200 handovers in success (Hilligoss & Cohen 2011, Manser et al. 2013).
five wards. Because of the variability between wards and Therefore, team-building interventions focusing on under-
hospitals in handover strategies, the findings might be lim- standing the respective work roles and their interdependen-
ited in generalization. However, given that the handover cies (Blickensderfer et al. 1993), developing trust among
strategies were observed in other studies (Patterson et al. the team and highlighting the importance of team situa-
2005, Philibert 2009), these findings do enhance the sparse tional awareness (Patterson & Wears 2010), seem most
existing literature by demonstrating links between indica- appropriate. Third, to facilitate checking the medical tech-
tors of the handover’s processes and its outcomes (Manser nology devices, structuring aids should support the team
& Foster 2011). Second, our findings showed differences communication process during handover by providing
among wards in treatment errors. Although the hospital’s room for assessments. For example, special time during
policy was to distribute patients evenly among wards, with handover could be devoted to checking the reliability of the
a relatively equal mix of illnesses and complexities, other medical equipment and reading written reports and notes,
factors, such as staffing or ward climate regarding patient’s preferably while the outgoing nurses are still on the ward
safety, could account for these differences. Third, our or can be reached by email or telephone. Obviously, it is
observational approach to measuring a handover’s strate- imperative that nurses be aware of these opportunities for
gies might be subject to bias, as participants may behave cross-checking. Fourth, although bedside face-to-face hand-
differently in the presence of an observer. Roter (1989) over allows patient involvement, previous research has
concluded that the ‘good impression bias’ that stems from showed that nurses seldom invite it (Patterson et al. 2005,
the presence of the observer is minimal, as individuals typ- Cheung et al. 2010). Targeting the participation of the
ically quickly become accustomed to the observer’s pres- patient and his or her family in the handover could be
ence and tend to behave naturally. Moreover, the achieved by teaching nurse’s communication strategies and
employment rate of the different strategies observed in this encouraging behaviours during handover such as calling the
study is consistent with previous research (Patterson et al. patient by name, being authentic, avoiding professional
2005, Philibert 2009), thus strengthening confidence in the jargon and responding to patients’ needs (Muething et al.
findings. Finally, it is plausible that the use of handover 2007).
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