Adrian J. Hayes, Rosalind Pool, Christopher Roughley, Sam Scholes, Laurence Sharifi, Rebecca Woodside, Siobhan Reilly, Poppy Roberts, Thomas Salter and Laura Singleton, Warwick Medical School, University of Warwick
The whole system is inherently dangerous. Um, but that is the way it always has been. And I think that it should get better, but it would be hard to make it better [Luke - F2 doctor]
As a result of changes in working patterns, handovers between doctors have recently become more frequent and more important for patient safety. In the UK there is wide variability between hospitals and departments as to how handovers take place, with no agreed structure. In this study, 19 doctors from three hospitals took part in qualitative, in-depth, semi-structured interviews to explore the problems encountered in handover and their consequences, as well as recommendations for improvement. Thematic analysis revealed a need for regular, well-attended handover meetings with clear, formal structure and a nominated lead. There was specific, vital content which needed to be communicated, as well as a balanced level of background detail. Participants had all experienced adverse incidents due to poor or missed handover while many felt a good system improved working relationships both within and between teams. Recommendations are made involving training, suggested format and staff representation in handover.
Keywords: Health services, handover, hand-off, patient safety, quality in care, junior doctors, qualitative research
When one shift ends and another begins, health care staff discuss their patients to review progress, status and plans for care. Handover has come under close scrutiny in the last ten years, with the British Medical Association (BMA), Royal College of Surgeons (RCS) and World Health Organisation (WHO) all publishing guidance in this area (BMA, 1994; RCS, 2007; WHO, 2007). One of the reasons for the current interest is reduction in working hours due to the European Working Time Directive, making staff changes more frequent. Studies have shown that handover is a time when patient care is vulnerable and prone to adverse consequences (Apker et al., 2007; Kitchet al., 2008; McCann et al., 2007; Woodward et al., 2010), and this can only be intensified by increasing the number of patient handovers needed.
The published guidance makes a number of recommendations concerning best practice for handover. The BMA (1994) advised that a multi-disciplinary team be present, with attendance from senior clinicians. They suggested that handover be organised for a fixed time and length, to be carried out within working hours. It should be free from interruption and succinct, with clear leadership. Similarly, RCS (2007) recommended that handovers be focused and structured, that they have a leader, and that they reduce inessential information. Similar recommendations also appear in American guidance; for example, the Agency for Healthcare Research and Quality which detail what information should be passed on between staff, including new clinical information, severity of illness, and detail of tasks to be performed during the next shift (AHRQ, 2012).
Limited empirical research has been conducted into handover to date, with most studies taking place in the US and focusing on nursing staff. However, many findings are relevant to handover between doctors in the UK. For example, a number of studies have demonstrated wide variation in practice (Arora and Johnson, 2006; Patterson and Wears, 2010), also highlighted in the BMA report mentioned above (BMA, 1994). Also common to this report is the finding that there is a lack of education and training in the process of handover (Dracup and Morris, 2008; van Eaton, 2010; Solet et al., 2005).
The few interventional studies in this area have shown improvements when there is written or electronic documentation (Anderson et al., 2010; Bhabra et al., 2007) and a standardised structure (Arora et al, 2009). However, most studies do not have the robust methodology needed to demonstrate the effectiveness of these attributes, nor do they report any differences in patient outcomes. An exception is Petersen (1998), who showed a reduction in preventable adverse incidents following implementation of 'computerized sign-outs'. Most mistakes appear to occur due to poor communication (Alvarado et al., 2006), and a recent study has attempted to improve this aspect of handover by a communication tool called ISBAR (Thompson et al., 2011). The junior doctors using this tool reported increased confidence in handover and in patient safety, though no patient outcome data is available. As yet there has been no successful attempt to show that adverse events can be prevented by improving communication or any other aspect of patient handover. Nursing studies have found that the most commonly reported problems in handover were in variable quality, insufficient information, lack of opportunity to ask questions, interruptions and limited time (Welsh et al., 2010), all of which appear common to handovers between junior doctors.
This study aimed to explore issues of handover as perceived by the doctors who take part in them every day. Our goal was to identify problems and their consequences on patient care, as well as to make recommendations for improvement in order to design a system of handover which could be piloted and further evaluated in the future.
This project used qualitative methodology and semi-structured interviews allowing participants to expand on areas they felt were important without constraint, and to bring up issues which had not been considered from the outset. We conducted in-depth interviews with doctors about their experiences of good and bad handovers, and the effects that these can have on patient care. The interview schedule (Appendix 1) was developed and refined in two pilot interviews. All interviewers were trained by the lead author (AJH) who had prior experience of conducting qualitative health care research, and who listened to audio recordings of each interview, providing feedback where necessary.
Participants were doctors of varying grades, but interviews concentrated on juniors (i.e. those in their first five years after qualification). Sampling was purposive; the team approached doctors working on wards where they were placed as part of their own medical training, and asked for suggestions for further participants. Under principles of qualitative research, the sample was not intended to be statistically representative of all doctors in the hospital nor for results to be generalised as the prevailing views of that population, but to provide in-depth discussion by a small number of individuals working in this specific environment. Recruitment and data collection ceased when 'saturation' was reached, i.e. when further collection of data did not reveal new information (Glaser and Strauss, 1967).
All 19 doctors who were approached agreed to be interviewed from three hospitals in the West Midlands. These included nine in their Foundation Years (first two years after qualification), five doctors in their Core Clinical Training (three years specialising in hospital medicine, following Foundation years), three registrars (specialist training in a specific medical specialty, following CCT), and two consultants. The focus of this study was on junior doctors, but a smaller number of more senior doctors were included who could draw on experience of handovers as both junior and senior clinicians. Between them participants had worked in 28 different medical and surgical specialties. The doctors interviewed worked in environments where there was a morning and evening handover, with variation as to afternoon and weekend handover between teams.
Interviews were audio-recorded with permission and transcribed by the team. The transcripts were explored using thematic analysis. This involved reading all transcripts a number of times, then coding small segments of text by description of their contents. Higher-order themes were then constructed from grouping similar codes. Themes were not stated a priori, but responses were arranged into themes developed through engaging with the data and drawing comparisons within and between interviewees. At every stage, quotations and codes were reviewed as to their relative fit within a theme, adjusting the structure as necessary to provide the best fit. These principles conform to those of Glaser's (1965) Constant Comparative Method for analysis of qualitative data. The process was carried out individually by three members of the team, who then met to discuss their own analysis. By discussing quotations, codes and themes, a consensus was reached over the most appropriate structure for the data.
In the presentation of our results, we have provided data on the number of respondents who discussed each theme. We have not provided detailed frequencies on agreement for every point, as the purpose of qualitative methodology is not to generalise to all doctors in the studied hospitals, but to discuss and explore issues thought important by individual respondents, regardless of whether they were predicted by the research team. Hence, where doctors did not refer to a particular point this does not mean they disagreed, but rather than the point did not come up in their interview.
Three broad areas emerged from transcript data, labelled 'content', 'format' and 'impact'. Within each area, individual themes are labelled and described below with representative quotations. Names have been changed to maintain anonymity.
All 19 interviewees discussed which patients needed to be handed over to the next shift, and agreed it was not necessary or desirable to hand over every patient. They also agreed on the importance of handing over anyone who was acutely unwell, or who might 'go off' during the next shift. Five also mentioned new patients, particularly new and unknown patients, as they are less predictable or need clerking in.
Go through the patients who have had problems overnight who have been sick, patients who you need to be aware of [Jenny - Foundation doctor]
Level of Detail
Thirteen doctors discussed the amount of detail provided in handover and complained about situations when they were given too much and not enough information. There appeared to be a certain 'vital content' which included name, hospital number and location, then a balance of which background and test results were needed to make sensible decisions on a patient's care. Eight described getting better at providing the relevant amount of detail at handover or that the juniors were worse than more senior doctors for deciding what to include. Therefore it seemed handover was a clinical skill learned through experience. Nine interviewees specifically mentioned that the importance of having information to include concerns about a patient, what had been done, and what still needed to be done. They wanted a clear plan, but also needed to know why this had been put in place so they could cope with a change in the situation. They did not want vague statements, or to be asked to do a general review (e.g. to 'keep an eye on' someone) because they may not know the patient and could not adequately interpret their condition.
My initial handovers were very, very poor...you've got to be incredibly clear about what you've done and your role... and make sure that all the relevant information is passed over [Jonathan - Foundation]
The thing about a bad handover is its very vague...It's up to you to put in order of priority what the patients need [Mary - CCT]
It's impossible to say "can you review my patient" every time because even though that's safe, um if you don't know the patient it takes too long [Luke - Foundation]
Assessment of Urgency
The severity of illness was often not communicated. Patients' condition could not necessarily be inferred from their diagnosis, but was often a mix of their signs, symptoms, investigation results, and general appearance. This was important in predicting the urgency of being called out to these patients during the shift, as well as planning the order in which to see patients.
When you're...called to a ward...you already know a little bit about them before you get there. Which can be really helpful in terms of knowing how fast to run. Haha. Or not [Richard - Registrar]
It's no good bringing to handover "I've not seen this patient but" - at least if you just eyeball them on the way to handover you can say "they're really sick, you need to see them first", or "I wouldn't worry about them...this evening'' [Hank - Foundation]
Seventeen doctors discussed their opinion that handovers should be more formal and less 'social' so that time was spent efficiently and no patients were missed. Most felt there should be a structure, though not a strict set of rigid rules which could slow things down if irrelevant. Furthermore, fourteen recommended having a named lead for handover. This person need not know every patient being discussed, but would chair the meeting, making sure it ran smoothly and efficiently. Eleven felt documentation was vital, many commenting that the best handovers they had attended were ones with physical copies of handover sheets being passed between staff.
It makes a difference if you've got somebody... to lead the events, so they kind of stop other people overtalking, who everybody kind of listens to [Rory - Registrar]
I worked somewhere where you get like an A4 page...split sections for wards that you can write who's a problem so that you've got, you know, everything in front of you...it's not on one scabby bit of paper that's covered in scribbles that you at 3 in the morning can't understand [Gail - CCT]
It's absolutely crucial that it's written and documented because...when things go wrong, you have no way of tracking back to see where they have gone wrong, or know how we can put in place a process or improve team working [Sam - Consultant]
Ten interviewees agreed the importance of attendance as second-hand information could give an incomplete view. Eleven felt it was key that senior-grade doctors (e.g. registrars) should attend, but there was disagreement over whether this needed to be a consultant. Some thought this was unnecessary and could be distracting, while others felt they provided leadership which would otherwise be absent. Eleven doctors recommended representation from nursing staff who have the most day-to-day patient contact.
It's really frustrating when if you're trying to handover events of the night and you're tired from a night shift and, um, the people you need to handover just haven't turned up [Richard - Registrar]
I think there should be nursing staff input...that would be a better idea...[but] they never have time [Toby - Foundation]
Eighteen interviewees recommended that handovers should take place in a dedicated room and at set times. They felt this regularity would reduce confusion about where and when to go for handover, consequently increasing attendance, punctuality and the perceived importance of the meeting. Several also discussed the importance of staff attitudes of handover being arranged within working hours and having a period of overlap with the following shift.
The worst handover is no handover at all [Sarah - Foundation]
You need to know exactly where it's gonna be and what time... then everyone kind of knows what to expect, and what's expected of them, and I think people kind of gain in confidence with the system [Rory - Registrar]
If it's not part of your working hours...you're probably desperate to get home [James - CCT]
Quality of Care
The most common quote for the consequences of poor handover was 'things get missed' (mentioned by fourteen interviewees), which appeared to represent a number of adverse scenarios, including patients not being seen, test results overlooked, confusion over care planning, and slowing the speed of patient care. All of the doctors were asked to describe a situation where they felt an adverse event had occurred as a result of handover and all were able to do so. Several said there were 'hundreds of examples', and that this was an 'everyday occurrence'. These were evenly split between patients not being seen due to a lack of handover, or the severity of a patient's clinical situation not being communicated. Eleven doctors specifically commented that poor handovers resulted in harm to patients.
It's just inefficient and unsafe, more work for the doctor, but definitely unsafe for the patient as well [Mary - CCT]
9 times out of 10 probably wouldn't have serious consequences but then when it does, it can be serious [Sarah - Foundation]
Every day we come across information that isn't passed on and for the majority most part it's fairly trivial and retrievable but occasionally, you know, it can be serious, of course delayed at best...it's really an everyday occurrence [Sam - Consultant]
It seemed that it was more likely for minor, everyday details to be missed. While not often serious in isolation, sometimes these individual lapses mounted up and caused a bigger problem. Interestingly, no participants mentioned situations when handing over too much information resulted in poorer care. Two specific events are detailed below to illuminate the problems that can occur with inadequate or missed handover.
A patient that the team thought had been discharged had actually been moved to another ward...I had to deal with the relatives in the middle of the night, who were taking their relative home, in high dudgeon that they hadn't been seen for 10 days... It could have been stopped at 100 different points in between, but it wasn't [Richard - Registrar]
Being called to an arrest...and there hasn't been a plan made...it's not been handed over to the night shift so they've not known anything about it...[the patient's death] might have been preventable but if it wasn't preventable might have had a nicer death than the death that they had, and also probably also would have been a much more pleasant experience for the staff around them [Gail - CCT]
Effect on Staff
Handovers had an effect on staff as well as patients. Nine doctors mentioned that poor handover could waste time, both from lengthy meetings and also from having to search for information which had not been passed on. It could also lead to stress and tension on a ward or for on-call doctors when plans were not clear, and this impaired decision-making. Three doctors described that where a critical incident did take place, they felt guilt and personally responsible if the handover was not as comprehensive as it could have been. Conversely, four discussed how regular and efficient handovers could improve morale within a team and relationships with other teams.
If you don't have enough information...you have to go find the notes, sit read through things...you're kind of taking away resources from one to another which is less beneficial [Rory - registrar]
It's really good for building a sense of team...a sense of belonging and sense of team work between the different teams because otherwise you wouldn't have any contact [Richard - registrar]
This project aimed to explore the process of handover amongst junior doctors, including good and bad aspects, how it could be improved, and the consequences of ineffective handover. As with all qualitative research, the results are not intended to be generalisable to all doctors, nor even doctors from the NHS Trust under study. Rather, this methodology aims to find common ground between participants, and to understand the issues as experienced by these individuals. This approach can provide rich data, including views and information which were not anticipated at the outset of the project.
The 19 doctors interviewed had a wealth of experience in many different medical and surgical specialties, reflecting the NHS training programme. The focus was on junior doctors so these participants were preferentially included, but with additional representation from more senior clinicians. All had experiences of occasions when poor or missed handovers had adversely affected patient safety, suggesting the importance of this topic to patient care. Mistakes appeared to be relatively common, though usually minor and resolved in subsequent patient contacts. In addition, they felt that good handover procedures could contribute to effective teamworking, as well as making individuals' job easier.
Participants spoke of vital information needing to be handed over between staff, but that the level of detail required was a skill improved by practice and experience. Most appeared to have learned this 'on the job' with little or no training or guidance. It may be that handover could be included in the undergraduate medical curriculum, taught as part of the existing 'clinical skills' modules. Students could practise handing over patient information with experienced doctors commenting on the level of detail given. Furthermore, students on hospital placements could attend handover, and even take an active role under supervision. This may mean that junior doctors have the basic skills on qualification and avoid errors of inexperience which could affect patient safety.
The participants discussed the format of handover in somewhat more detail than the content. The overall impression was that in order to be taken seriously, the process needed to be more disciplined, with consistent organisation and a chair leading events. Doctors suggested this would improve attendance, and also attention during handover so that all present would be aware of information handed over. A number also suggested the presence of nursing staff who could give their opinions and take on relevant clinical tasks.
The following recommendations are made on the basis of the results:
- Induction for F1 doctors should emphasise the importance of handover.
- Medical students should attend handovers to learn the necessary skills early.
- Handover should take place in a dedicated room at regular times each day.
- Meetings should have a nominated lead, and include nursing representation. There should be a register of attendance.
- Handover sheets should be used with written/electronic documentation.
The recommendations are similar to those made by agencies in the UK and US (BMA, 1994; RCS, 2007; AHRW, 2012). However, the fact of them being made again here shows their importance and relevance to current clinical practice. The junior doctors here all had extensive experience of patient harm which had come about as a result of non-adherence to these principles. Furthermore, while the recommendations may not be new, they have clearly not been sufficiently implemented, and this may need to be addressed at a local level, with each hospital looking at their own procedures in an effort to reduce adverse events. We hope to use these recommendations to influence practice locally, and trial updated procedures. Finally, the study shows the positive impact senior hospital clinicians and managers can foster by including junior doctors and medical students in measures to improve patient safety.
This project was supported by a grant from the Reinvention Centre for Undergraduate Research, University of Warwick. Thanks to all the doctors who agreed to be interviewed.
1. Which specialties have you worked in since qualifying?
2. Tell me about your experience of handovers.
Prompts: What makes a bad handover? What makes a good handover? Impact of staff attitude/discipline in meeting/structure/setting/leadership?
3. How could handovers be improved?
[Base on answers to Question 2] Prompts: How could they be more efficient? Who should attend? Where and when should they be held? Should there be a lead/chair? How should they run? What is stopping them being run in this way? How should they be structured?
4. What are the consequences of bad handovers?
Prompts: Problems for patients? Problems for staff? Legal problems? Effect on timekeeping? Culture of ward/hospital?
5. Tell me about a time when a problem has occurred because of poor handover.
 All of the authors of this paper are currently final-year students at Warwick Medical School, and have been offered posts as Foundation Year 1 doctors to begin in August 2012.
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To cite this paper please use the following details: Hayes, A. J., Pool, R., Roughley, C., Scholes, S., Sharifi, L., Woodside, R., Reilly, S., Roberts, P., Salter, T. and Singleton, L. (2012), 'Communication and miscommunication: Handover between Junior Doctors', Reinvention: a Journal of Undergraduate Research, Volume 5, Issue 1, http://www.warwick.ac.uk/reinventionjournal/archive/volume5issue1/hayes Date accessed [insert date]. If you cite this article or use it in any teaching or other related activities please let us know by e-mailing us at Reinventionjournal@warwick.ac.uk.