Doctors' handovers: content and process

Research into doctors' handovers has generally focused on content and process by conducting questionnaire surveys, observations and, occasionally, critical incident interviews.3 19 20 Only one study (in US emergency departments)21 identified the stages used for change of shift handovers. Doctors' handovers were observed, and interview and questionnaire data were collected from clinical staff whose work could potentially be affected by these handovers. From the analysis, five stages of handover were proposed: anticipatory, preparatory, handover, immediate posthandover and the posthandover phase.

Junior doctors in two paediatric acute care wards completed a questionnaire assessing quality of the prenight shift handover. Items asked about the adequacy of the information received and where doctors retrieved any missing information. Based on 158 (81%) responses, Borowitz et al22 found that 31% of the residents indicated something had happened while they were on call that the handover had not prepared them for; and that the only variable influencing doctors' perception of preparedness for their night on-call was the quality of the handover. Despite handovers being a frequent activity between doctors, important information is often not transmitted. Bomba and Prakash23 examined doctors' shift changes by questionnaires, interviews and on-site observations. Inadequate handovers were related to medical record keeping (ie, illegible notes, lack of format or structure, errors or incomplete patient information), poor communication and lack of formal, systematic handover processes, especially for after-hours, on-call junior medical staff.

This lack of a formal system has been reported in other observational studies that have shown that there is often no designated handover time or place,24 or there was no formal requirement to attend handover.25 Medical handovers tend to be idiosyncratic.23 25 26 Residents surveyed at three hospitals reported no uniformity in how they signed out after their shift.27 Many signed out verbally ‘wherever and whenever’ they could find the cross-covering doctor. Similarly Laxmisan et al26 noted from observations in an emergency department (ED), that shift handovers were conducted based on incoming and outgoing doctors' preferences. Of 202 internal residency programmes in the USA, 55% did not consistently require both written and oral sign-out during handover,28 a finding that was replicated,29 30 with key clinical information available only two-thirds of the time in written or oral sign-outs of junior doctors. Such findings have led to calls for a more structured approach to doctors' shift handovers, although some argue that this would require a change in administration procedures and organisational culture.23

Content and process have also been examined by studying doctors' perceptions on current handover practices.31–33 Ye et al34 surveyed registrars (n=17) and consultants (n=33) working in three EDs and found that doctors perceived handovers as inaccurate, disorganised, confusing and as having incomplete information. The presenting problem, patient management, investigations undertaken and disposition plans were most commonly reported as the minimum information required from handover.

Communication failures during doctors' handovers

While poor communication has generally been cited as the root cause for inaccurate information transfer in handovers, resulting in almost 60–70% of sentinel events,6 little research has scrutinised types of failures. Arora et al19 interviewed 26 junior doctors who had been on-call one night using the critical incident technique20 to examine whether communication failures during verbal and written handover may have resulted in any patient harm. Communication problems included content omissions, failure to communicate the rationale of a decision, and a tendency not to discuss anticipated problems. A lack of face-to-face communication is a factor in critical medical incidents35 36 with failures to capture errors during information transfer.

Cultural, environmental and human factors affect the effectiveness of information transfer during doctors' handovers.3 37–39 Organisational factors, such as the lack of designated times and locations for handover, often lead to interruptions, which can affect the quality of information transfer. Tokode et al24 surveyed general surgical units in 17 hospitals. Problems in information transfer were often caused by interrupted handovers, a lack of designated time for handover and a mismatch with junior and senior doctors' work hours, such that senior consultants were not always able to attend handover and thus provide feedback to junior doctors.

Communication barriers were revealed in doctors' perceptions of the quality of handover between ED and internal medicine units.3 Semistructured interviews showed that patient handovers between units were seen as a ‘grey zone,’ full of ambiguity and uncertainty. Poor communication practices, such as incomplete and omitted information, caused this problem, because ED doctors and in-patient doctors had conflicting information expectations stemming from their contrasting approaches to patient care. Other failures in information transfer can occur during the sign-out (ie, end of shift) of the outgoing doctor.28–30 Arora et al40 reported that 1876 of 6942 medication chart entries contained discrepancies with the junior doctors' sign-out report. These were mainly information omission (eg, information from medication lists were not included in the sign-out report). In contrast, Wilson et al's41 observational-interview study of a paediatric ward found that the discussions of diagnoses and treatments during handover served as an opportunity to check that important jobs had been completed. Thus, handovers can contribute to an organisation's resilience42 43 because they provide clinicians with an opportunity to capture any errors or threats to patient safety.

Training and education: research to improve the quality of handovers

With the implementation of WTDs, more junior doctors are conducting shift handovers,1 17 18 44 45 but rarely receive formal handover training.45 46 Since many junior doctors feel unprepared, or their handovers are viewed as poor quality,45 it has been suggested that formal training is essential.36 45

Horwitz et al46 developed an oral sign-out curriculum for junior doctors in internal medicine that makes participants aware of: the importance and consequences of poor sign-out, the ideal content (both written and oral), and the SBAR briefing tool (situation, background, assessment, recommendation47). This led to a new verbal sign-out tool: SIGNOUT (sick, identify data, general hospital course, new events, overall health status, upcoming possibilities with plan, tasks to complete, any questions) that has been tested with junior doctors and medical students. Each participant signed out a patient on their list to a ‘receiving’ doctor, then gave feedback on the quality of sign-out (ie, structure, clarity, and omitted or irrelevant information). The training was generally well received, and the mnemonic tool was regarded as useful and comfortable. However, despite feedback after each sign-out, the junior doctors still struggled to remember to provide anticipatory guidance or to read back instructions to the sender.

Similarly, Arora and Johnson48 proposed a model for developing a standardised handover protocol to train junior doctors and registrars. This would enable doctors to become aware of each other's roles and perceptions of the task. A comprehensive understanding of the content of the handover was needed, in order to create a standard checklist. As an alternative to developing support tools, some researchers have assessed how taking part in ward rounds may affect doctors' oral handover skills. Stiles et al49 surveyed junior doctors' and registrars' (n=25) perceptions of the quality of morning report as an educational tool to aid handover. All the doctors surveyed believed that a consultant's presence was critical to education at handover morning report, and 84% believed this report would benefit from senior registrar led discussions. Fassett and Bollipo50 also surveyed junior doctors' perceptions of morning medical handover report and noted similar findings.

Non-electronic communication tools

Handover tools (eg, standardised cards) have mainly been explored using observations and questionnaires. Lee et al51 compared the use of a new sign-out card with other non-standardised methods. Over the course of 92 days, 19 junior doctors participated (10 allocated to the sign-out card intervention group and nine controls). Participants completed a questionnaire about the quality of sign-out they had received after a night of being on-call and left their completed sign-out sheets after each shift for comparison. Those using the sign-out card were less likely to omit patient information such as patient code status (74% completed in the intervention group versus 22% in the control group). Also, poor sign-out was reported by 5.8% of the interns in the intervention group and 14.9% of the control group. Determining the full effects of Lee et al's sign-out tool is hampered because they did not describe the types of non-standardised sign-out methods for the control group.

Bharba et al52 examined effective handover methods using a simulated handover scenario during which five senior house officers performed one-to-one handovers of patients verbally, in writing or with preprepared handover sheets (oral and written). Less patient information was omitted when handover sheets were used compared with when information was only spoken. Although this is one of the few studies using objective measures, it was conducted in a quiet room and so would need to be replicated under more realistic clinical handover conditions.

Tools such as mnemonics have been tested, as they can act as a common language for critical information, thus increasing the likelihood of information retention.47 53 54 Situational briefing techniques (eg, SBAR) have been used to give a standard communication framework for handovers.47 53 They may improve efficiency by aiding anticipation of what information will be required and the level of detail.55 The WHO54 specifically suggests using SBAR as a means of standardising handover practices. Other mnemonics include JUMP,25 where the doctor handing over states the jobs outstanding, the unseen patients, medical contacts and patients to be aware of. The usability of the JUMP mnemonic has yet to be tested, and like other mnemonics for example SBAR, further studies are needed to examine their effectiveness in healthcare.

Electronic sign-out systems and other IT solutions

Efforts to improve handovers have looked to information technology (IT) solutions.35 38 41 56 These have mainly concentrated on the sign-out report. However, computerised tools should be designed to aid communication between doctors, during handover preparation, as well as the handover itself and subsequent activities. These electronic solutions are designed to improve the accuracy of information transfer, but do not take into consideration the behavioural aspects and, therefore, do not always assess all the functions of handover. In an interview study, Sharit et al36 found that some doctors believed that IT solutions for handover were adopted for the sake of employing new technology, without improving communication.