A new study has improved the patient-centredness of nursing handover through a targeted, locally designed intervention to address the communication and systemic factors affecting handover.
Ineffective communication during nursing handover jeopardises patient safety and limits patient participation. A new study conducted as part of a Communication in Nursing Handover project showed improved ward handover practices on one ward of a NSW metropolitan teaching hospital that had experienced difficulties implementing hospital handover policy.
Professor Diana Slade, Director of the ANU Institute for Communication in Health Care and project lead, explained that the research team’s innovative approach to improving handover promoted a ward culture that prioritises patient-centred care and patient safety.
“What we have learned from this project is that there are two key factors that enable meaningful, impactful and sustainable change hospital wards. Firstly, support and collaboration with clinicians, ward leadership and management at all levels of the hospital are crucial. Secondly, training alone is not enough. It must be accompanied by ward and system-level changes. Improving communication practices in a ward changes the culture, and only then does the intervention result in sustainable change.”
The research team conducted interviews with nursing, medical and allied health staff and nursing students to elicit insider perspectives on the problems and challenges with ward handover practices. They also observed and recorded naturally occurring nursing handovers and multi-disciplinary meetings.
Analysis revealed several shortcomings in handover delivery and communication.
Handover occurred in the corridor or just inside the patient’s room rather than at the bedside. One nurse said that nurses were ‘always thinking that confidentiality was an issue’, which hampered their ability to conduct handover at the bedside in earshot of other patients.
Patient involvement in handover was low and often limited to a greeting, even when nurses gave handover at or near the bedside. Patients were not introduced to the incoming team or invited to contribute. Relatives were rarely invited to participate in handover. When they did contribute, the nurse did not acknowledge or respond to their comments with empathy.
The information provided in handover was inconsistent and lacked structure, despite hospital guidelines mandating the use of ISBAR. One student nurse noted that nurses ‘hand over what happened during the shift and that’s about it’. It was commonplace for nurses to omit the Recommendation stage of ISBAR, which poses risks to continuity of care.
These communication issues were shaped and constrained by systemic factors in the organisational and cultural context of the ward, as shown below.
In terms of organisational constraints, nurses lacked awareness of hospital handover policies. The research team observed that handovers rarely started on time, ran longer than recommended and were frequently interrupted.
Cultural barriers to handover included a culture of non-accountability where nurses did not see themselves as responsible or accountable for all ward patients, a lack of valuing of and commitment to patient-centred care, and hierarchical constraints against speaking up about concerns or asking questions.
Based on these findings, the research team developed an intervention consisting of 18 recommendations to improve ward handover practices, including delivery of communication training in ISBAR and CARE (Connect, Ask, Respond, Empathise) protocols to address the informational and interactional risks identified in the data.
The NUM oversaw implementation of the recommendations covering handover events, handover tools, cultural change and mentoring and handover policy. The nursing handover sheet was redeveloped to reflect the ISBAR protocol and better support nurses delivering handover. The NUM and CNE also undertook real-time mentoring to reinforce training in the ISBAR and CARE protocols and support staff through the transition to bedside handover.
The research team returned to the ward six weeks after the intervention to assess its impact on ward handover practices and attitudes. The post-intervention data revealed improvements to the quality and safety of patient care.
“By actively involving patients and their colleagues in bedside handover and providing more complete and comprehensive transfer of information, nurses recognised handover as an opportunity to provide patient-centred care and reduce patient harm,” said Professor Slade.
In terms of improvements to patient safety, there was an associated decrease in reported hospital-acquired complications. This included a 48% reduction in inpatient falls, a 20% decrease in the hospital-acquired pressure injuries and a 43% reduction in medication errors.
Looking at changes to quality of care, there was a marked increase in patient and carer participation in bedside handover, improved ward-level communication, ward organisation and nursing culture.
Handovers routinely took place at the patient’s bedside following the intervention. Nurses acknowledged the benefits of this for patients (they know ‘the exact nurse who’s going to be looking after you through the day’) and nurses (‘When you’re around the bed, you seem to just look on the board behind them, their mobility, the patient’s face, how they’re sitting, how they’re positioned. Small things like that made a big difference in terms of how we can look after this patient better’).
Nurses actively involved patients in handover through applying the CARE protocol. Nurses routinely greeted patients and introduced them to the incoming team. Nurses encouraged patients to contribute information and responded appropriately when they did.
Nurses also showed a deeper appreciation for patient-centred approaches to care, reflecting on the many benefits of involving patients in handover. Nurses explained that they were now ‘more up-to-date with what’s going on with the patient’. They noted that patients could contribute information, correct errors, provide missing information and answer questions.
Following the training, the information provided in handover was more often sequenced according to the ISBAR protocol. Nurses noted the importance of redesigning the handover sheet by ISBAR to facilitate this change.
Importantly, the intervention provided the impetus for positive change to aspects of ward nursing culture. Nurses commented that the training had ‘encouraged them to be accountable for this shift and the care that they’ve provided’. It also facilitated a turnaround in the hierarchical aspects of ward culture. Nurses embraced a culture of mentoring and modelling practice to student and junior nurses.
The intervention has been rolled out to a further five wards across two hospitals.
Read the full study here.