Handovers: definitions and purpose

Messam and Pettifer (Reference Messam and Pettifer2009) and Smeulers, Lucas and Vermeulen (Reference Smeulers, Lucas and Vermeulen2014) identified four styles of nursing handover. These were:

1. 1. Bedside: located at the patient's bedside, which promotes patient and nurse face-to-face interaction and encourages patients’ verbal participation.

2. 2. Verbal: located in an office setting, the nurse responsible for a group of patients exchanges relevant documented information.

3. 3. Non-verbal: located in an office setting, nurses inform themselves by reading the patient health record, including progress notes, medication and observation charts and nursing care plans.

4. 4. Taped: located in an office setting, the nurse in charge collects the relevant information and records this on to an audiotape so that the oncoming shift can listen at a convenient time (Smeulers, Lucas and Vermeulen Reference Smeulers, Lucas and Vermeulen2014: 3).

While verbal handovers are ‘traditional’ (Messam and Pettifer Reference Messam and Pettifer2009: 190) and staff tend to prefer face-to-face handovers (whether at the bedside or in an office) over those which are not (Frankel et al. Reference Frankel, Flanagan, Ebright, Bergman, O'Brien, Franks, Allen, Harris and Saleem2012), there is a lack of experimental studies identifying whether different styles of handover result in any better outcomes for patients (Manser and Foster Reference Manser and Foster2011; Smeulers, Lucas and Vermeulen Reference Smeulers, Lucas and Vermeulen2014). Instead, each type of handover is usually presented as having its own set of advantages and disadvantages. For example, verbal handovers offer opportunities to clarify information, while audio taped or written handovers do not require an overlap between shifts (Tucker and Fox Reference Tucker and Fox2014).

A striking feature of existing published research on handovers in hospitals is their variability. External factors, such as noise, workloads, interruptions and the need to attend to patients are all thought potentially to impact on handover quality (Manser and Foster Reference Manser and Foster2011; Streitenberger, Breen-Reid and Harris Reference Streitenberger, Breen-Reid and Harris2006). Researchers have also suggested that handovers are influenced by their ritualistic nature, organisational culture and leadership (David et al. Reference David, Holroyd, Jackson and Cleary2017; Holly and Poletick Reference Holly and Poletick2014; Streitenberger, Breen-Reid and Harris Reference Streitenberger, Breen-Reid and Harris2006; Tucker and Fox Reference Tucker and Fox2014). This variation helps explain why so much of the research interest in handovers has been led by clinicians and organisations concerned with patient safety. A commonly cited statistic in the handover literature is the statement made by the Joint Commission (an independent, not-for-profit organisation accrediting and certifying health-care organisations and programmes in the USA) that ineffective communication in handovers plays a ‘role in an estimated 80 per cent of serious preventable adverse events’ in hospitals (Joint Commission 2011, cited in Popovich Reference Popovich2011: 55). Adverse events are usually defined as an unintended injury or complication resulting in prolonged hospital stay, disability at the time of discharge or death, caused by health-care management rather than by the patient's underlying disease process (de Vries et al. Reference de Vries, Ramrattan, Smorenburg, Gouma and Boermeester2008: 216).

Attempts have been made to reduce the risk of adverse events by standardising the handover process. This mainly involves using structured tools, such as the ‘Introduction, Situation, Background, Assessment (ISBAR)’ (Aldrich et al. Reference Aldrich, Duggan, Lane, Nair and Hill2009), the 30-Second Head-to-Toe checklist (Popovich Reference Popovich2011) or the REED (Record, Evidence, Enquire, Discuss) model (Tucker and Fox Reference Tucker and Fox2014).

Before discussing the factors influencing long-term care provision that might affect the nature and practice of handovers in care homes, it is worth highlighting one final point about existing research on hospital handovers. Streitenberger, Breen-Reid and Harris (Reference Streitenberger, Breen-Reid and Harris2006) argue that poor handover information means mistakes are more likely to be made when patients are unable to advocate for themselves and are temporarily or permanently reliant on others to meet all their care needs because the patients themselves are unable to intervene themselves by, for example, questioning why a particular treatment is being given or appears to have been forgotten. To this end, existing research about hospital handovers has investigated handovers in paediatric wards (Popovich Reference Popovich2011; Streitenberger, Breen-Reid and Harris Reference Streitenberger, Breen-Reid and Harris2006), operating theatres (Randmaa et al. Reference Randmaa, Swenne, Martensson, Högberg and Engström2016) and intensive care (Mukhopadhyay et al. Reference Mukhopadhyay, Leong, Lua, Aroos, Wong, Koh, Goh, See, Phua and Kowitlawakul2015). However, the position of older people who might also be unable to advocate for themselves, such as those with speech problems following a stroke or those with dementia, appears to be strikingly absent.

Factors influencing the provision of residential long-term care

Residential long-term care is typically seen as part of a continuum (e.g. McGrail Reference McGrail2011; Park-Lee et al. Reference Park-Lee, Caffrey, Sengupta, Moss, Rosenoff and Harris-Kojetin2011), ranging from facilities providing 24-hour support with activities of daily living, such as washing and dressing, to skilled nursing facilities providing sub-acute care for those requiring complex care or rehabilitation. The Organisation for Economic Co-operation and Development estimates that residential settings comprise only about a quarter of all the long-term care provided to older people in its member countries but they account for almost two-thirds of its costs (Colombo et al. Reference Colombo, Llena-Nozal, Mercier and Tjadens2011). While increases in the proportion of people aged 80 and over are the key factors influencing demand for residential long-term care, the size of the sector and the type of support it provides within different countries are also influenced by national and local political priorities (Lievesley, Crosby and Bowman Reference Lievesley, Crosby and Bowman2011) and the size and mix of publicly and privately funded long-term care (Colombo et al. Reference Colombo, Llena-Nozal, Mercier and Tjadens2011). In turn, these political and funding differences influence the way that long-term care services are regulated (Mor, Leone and Maresso Reference Mor, Leone and Maresso2014).

Care home sector in England

In England, the generic term ‘care home’ is used to describe long-term residential care facilities which are divided into those ‘with’ or ‘without’ nursing care (Orellana Reference Orellana2014). Care homes must be registered with the regulator, the Care Quality Commission. Where owners are not in day-to-day charge of the service themselves, they have to appoint a registered manager to manage it on their behalf (Care Quality Commission 2017b). Some registered managers have a professional qualification such as nursing or social work; others are appointed on the basis of vocational qualifications. However, the numbers in each group are unknown (Orellana, Manthorpe and Moriarty Reference Orellana, Manthorpe and Moriarty2017). In addition, care homes ‘with nursing’ (often referred to as nursing homes) are required by law always to have a registered nurse on duty, whereas homes ‘without nursing’ (sometimes referred to as residential homes) are not.

As of 2015 (the latest year for which published figures were available), there were 11,000 care homes without nursing in England and 4,600 homes with nursing provided by around 7,913 different organisations. Between 2009 and 2015, there was a 10 per cent decline in the number of homes without nursing and 7 per cent rise in the number of homes with nursing (Davison and Polzin Reference Davison and Polzin2016). A distinctive feature of care homes in England is that the great majority are in the commercial sector, which includes both large corporate chains and small family-run homes. While the average size of a home is approximately 20 places, there are almost 3,000 homes with five or fewer places, and only 10 per cent have more than 50 places (Oscar Research n.d.). In terms of how these places are funded, Passingham, Holloway and Bottery (Reference Passingham, Holloway and Bottery2013) cite data from Laing and Buisson, a commercial market intelligence company, suggesting that 44 per cent of people living in a care home in England pay their fees themselves, 36 per cent are funded entirely by their local council because they have assets below £23,250, a further 14 per cent use ‘top-up’ fees paid by a relative to supplement the fees paid by their local council, while the remainder are funded by the National Health Service. These data are not sub-divided by age.

Staffing levels are currently under pressure in many care homes in England. This is a long-standing problem (Hussein, Ismail and Manthorpe Reference Hussein, Ismail and Manthorpe2016) worsened by evidence that the 2008 economic crisis has resulted in cuts in staff to resident ratios, in the ratio of qualified to unqualified staff, and to reductions in pay, all of which can contribute to diminished handover procedures in some homes (Burns, Hyde and Killett Reference Burns, Hyde and Killett2016). Care home owners have specifically warned about the consequences of the introduction of the National Living Wage, which specifies the minimum pay per hour most workers are entitled to by law. They complain that local councils have not raised the fees they pay care homes to support publicly funded residents in line with their increased wage bills (Low Pay Commission 2016).

Owners have also expressed concern that pressure from commissioners and regulators to improve the quality of record keeping as a way of improving standards of care and increasing accountability has led to care homes becoming over-burdened with ‘paperwork’, including recording what happens from one shift to the next (Warmington, Afridi and Foreman Reference Warmington, Afridi and Foreman2014). The combination of staff cuts, low pay, increased demand and regulatory pressures to improve record keeping places considerable pressure on staff time. This could, in turn, have an impact on the quality of information exchange about care home residents and on their consequent comfort and safety. Care homes themselves comprise ‘complex and often contradictory environments with their mixture of private and public spaces, individual and communal existences, a home for residents and a work place for staff’ (Kenkmann et al. Reference Kenkmann, Poland, Burns, Hyde and Killett2017: 8). While they often resemble each other in terms of layout and in the support needs of those who live in them, their cultures may differ substantially (Luff, Ferreira and Meyer Reference Luff, Ferreira and Meyer2011). The combination of funding pressures, difficulties in recruiting and retaining staff, regulatory pressures to improve standards of record keeping, and differences between homes in terms of their ownership, culture and clientele suggest it is worth exploring whether shift handovers provide a microcosm of the current care home environment in England.

Handover style

Conceptually, shift handovers in care homes appeared to be influenced by nurse shift-to-shift handovers in hospitals. As with studies of nurses (Messam and Pettifer Reference Messam and Pettifer2009; Smeulers, Lucas and Vermeulen Reference Smeulers, Lucas and Vermeulen2014), different types of handover – verbal, non-verbal and taped – were reported but the studies identified did not consider whether the amount of nursing care provided in each setting influenced handover style or length. Verbal handovers typically took place at each change of shift and were reported as being brief (often around 15 minutes), relaying only pertinent information from the previous period of work (Burns, Hyde and Killett Reference Burns, Hyde and Killett2016; Haines and Davey Reference Haines and Davey2011; Lyhne et al. Reference Lyhne, Georgiou, Marks, Tariq and Westbrook2012; Wheeler and Oyebode Reference Wheeler and Oyebode2010).

An important cross-cutting theme in five of the six Australian studies retrieved for this review was a trend towards the use of electronic health records to replace verbal handovers and paper records (Gaskin et al. Reference Gaskin, Georgiou, Barton and Westbrook2012; Lyhne et al. Reference Lyhne, Georgiou, Marks, Tariq and Westbrook2012; Munyisia, Yu and Hailey Reference Munyisia, Yu and Hailey2011; Tariq, Georgiou and Westbrook Reference Tariq, Georgiou and Westbrook2013; Zhang, Yu and Shen Reference Zhang, Yu and Shen2012). These emphasised the potential for information technology to reduce duplication and minimise errors. While some staff were reported to prefer face-to-face communication, they generally recognised the advantages of electronic records. Even so, electronic records did not appear to have completely replaced paper care plans and handover books (Lyhne et al. Reference Lyhne, Georgiou, Marks, Tariq and Westbrook2012; Zhang, Yu and Shen Reference Zhang, Yu and Shen2012). A further reported disadvantage – remembering that these studies pre-dated the wide availability of hand-held devices – was that electronic information was not available at the point of care and electronic records and care plans had to be updated using paper-based records at the end of a shift (Gaskin et al. Reference Gaskin, Georgiou, Barton and Westbrook2012; Lyhne et al. Reference Lyhne, Georgiou, Marks, Tariq and Westbrook2012).

No examples of bedside handovers in which discussion about the previous shift and establishing agreement about what needed to be done during the following one takes place alongside the resident were identified in the studies included in the review. Bedside handovers have increased in popularity in some hospitals as a way of helping patients to become more involved in their care and improve the quality of information sharing (National Nursing Research Unit 2012). The absence of resident involvement in care home handovers may be the result of concerns that bedside handovers would take longer and that residents might be asleep when handovers took place late at night and early in the morning. Instead, handovers generally took place in the home's office or, in one study, at the nurse's work station or care team room (Lyhne et al. Reference Lyhne, Georgiou, Marks, Tariq and Westbrook2012). Place and space are not neutral (Kenkmann et al. Reference Kenkmann, Poland, Burns, Hyde and Killett2017). In this sense, the discussions that take place between staff in areas that are ‘off limits’ to residents become part of the power dynamic in care homes and highlight the absence of residents’ voices in the process of handover. As we describe below, they may also exclude those who are directly involved in providing care.

Extent of staff involvement

There was considerable variation in terms of whether handovers involved all staff, including care workers and other staff involved in domestic services such as laundry or cooking, or whether they were restricted to senior staff (Bennett et al. Reference Bennett, Ward, Scarinci and Waite2015; Wheeler and Oyebode Reference Wheeler and Oyebode2010). Research from hospital settings (Schneider et al. Reference Schneider, Scales, Bailey and Lloyd2010) shows that even if everyone is present at a handover, it does not mean that different grades of staff contribute equally. Care workers felt that their input was not always valued during handover or described how they often found themselves unsure of what to do in their duties because of incomplete or conflicting communication from superiors, as well as insufficient information provided during handover. They felt these experiences reduced their job satisfaction and meant they were more likely ‘to call in sick’. They also thought their poor morale had a ‘flow on’ effect on the residents (Bennett et al. Reference Bennett, Ward, Scarinci and Waite2015: 1999).

Financial constraints, as well as status, could also influence who attended handovers. Burns, Hyde and Killett (Reference Burns, Hyde and Killett2016: 1003) contrasted one home in which all staff were involved in handovers with another where cutbacks in fees paid by the local council led to a decision not to pay care workers to attend handovers. It was not clear from this account whether this decision also applied to other grades of staff, such as senior care workers or shift leaders. In the home in which all those beginning a shift, including care workers, took part in the handover, everyone was involved in ‘throwing ideas around on how to do things for each of the residents’. This was thought to contribute to the home being given an ‘excellent’ rating by the regulator. By comparison, care workers in the other home were reliant on the information passed on to them by the senior staff on duty. The care workers themselves did not consider this to be adequate and developed their own informal handover by ‘huddling together to share information and to discuss which parts of the workload each would do’ (Burns, Hyde and Killett Reference Burns, Hyde and Killett2016: 1004). The absence of care workers during handover meant that opportunities to use handovers for training or supervision were also missed.

This example of an informal handover contrasted strongly with the procedure written by a local council in which staff were instructed not to ‘catch up with each other socially’ or to ‘drink tea and coffee’ during the handover, which was to be ‘chaired’ by the Duty Officer, a designated senior member of staff (Haines and Davey Reference Haines and Davey2011: 3–4). While the hospital-based literature on handovers identifies their unofficial purpose in contributing to team building and peer support (Holly and Poletick Reference Holly and Poletick2014; Kerr Reference Kerr2002), this document provided an illustration of the way in which handovers in care homes could reinforce hierarchical distinctions between staff.

Infrastructural context of handovers

Many quality improvement interventions hinge on the introduction of artefacts to support behavioural change in the workplace but few evaluations analyse whether they are operating as intended. For example, many technologies intended to reduce paperwork have the opposite effect (Allen Reference Allen2012: 460). On the basis of the studies reported here, artefacts designed to improve handovers had a mixed effect. Zhang, Yu and Shen (Reference Zhang, Yu and Shen2012) reported that staff thought it was quicker to record information on electronic health records than to write them by hand. It was also easier to share information with other professionals. Tariq, Georgiou and Westbrook (Reference Tariq, Georgiou and Westbrook2013) highlighted that handwritten medication records were often illegible – thus increasing the potential for mistakes to be made. Set against these reported advantages, Lyhne et al. (Reference Lyhne, Georgiou, Marks, Tariq and Westbrook2012) concluded there was still a considerable amount of duplication, including the need for registered nurses to carry a written handover sheet throughout the shift which then had to be transferred to the electronic record before the next shift arrived on duty. Bland (Reference Bland2007) highlighted the pressures on nurses from regulators and employing organisations to provide more detailed written information about residents. This had, she observed, resulted in them spending more time in the office writing care plans rather than supervising what care staff were doing. However, as her field notes revealed, despite the ‘enormous amount’ of registered nurse time ‘spent developing supposedly individualized care-plans, they were often inaccurate, incomplete, out of date, or ignored by care delivery staff’ (Bland Reference Bland2007: 941).

Choice versus routine

Care homes have a unique culture in the sense that their environment is simultaneously somewhere that is communal, an individual's home and a workplace (Bland Reference Bland2007; Kenkmann et al. Reference Kenkmann, Poland, Burns, Hyde and Killett2017). There is a well-established gerontological literature that explores the organisational culture of care homes and how it sometimes includes task-focused routines – such as undertaking certain duties at particular times of the day – that appear to operate more in the interests of staff than residents (Bland Reference Bland2007; Killett et al. Reference Killett, Burns, Kelly, Brooker, Bowes, La Fontaine, Latham, Wilson and O'Neill2016). A universal theme of research on handovers both in hospitals and care homes is how they are used to promote residents’ safety (Frankel et al. Reference Frankel, Flanagan, Ebright, Bergman, O'Brien, Franks, Allen, Harris and Saleem2012; Tariq, Georgiou and Westbrook Reference Tariq, Georgiou and Westbrook2013). How this might conflict with individual residents’ preferences is explored less often. Luff et al. (Reference Luff, Ellmers, Eyers, Young and Arber2011) investigated the amount of time that residents spent in bed at night, focusing on how residents’ bedtimes and getting-up times were managed. They found that shift timings and handovers were seen by some residents as designed to meet staff needs rather than those of residents. For example, one resident would have preferred to go to bed between 9.30 and 10 pm but this time coincided with handover when fewer staff were available to help. She chose to go to bed earlier rather than risk waiting until the incoming night staff could help her. In this instance, the combination of handovers and the practice of employing fewer people at night than during the day combined to reduce residents’ choices.

Effectiveness

The limited nature of research about handovers in care homes meant that it was unsurprising that that there was so little information on their effectiveness. A series of focus groups held with relatives of people living in nursing homes on behalf of the Care Quality Commission (2013) (the regulator for health and social care in England) included ‘efficient handovers’ as an indicator that a home was ‘well led’ but did not describe in any further detail what these might involve. The study by Luff et al. (Reference Luff, Ellmers, Eyers, Young and Arber2011) was the only one that we were able to identify that specifically discussed handover practices in terms of residents’ quality of life. While Bland (Reference Bland2007) also made links between poor information sharing and residents’ ‘comfort’, she did not specifically refer to handovers in this context. Care workers participating in the studies undertaken by Bennett et al. (Reference Bennett, Ward, Scarinci and Waite2015) and Wheeler and Oyebode (Reference Wheeler and Oyebode2010) were concerned that poor communication, including that provided at handover, hindered their ability to provide good care. However, Munyisia, Yu and Hailey (Reference Munyisia, Yu and Hailey2011) highlighted the methodological challenges of being able to show causal links between handovers and other types of verbal or written communication to direct benefits for care home residents.