Structured Handovers of Nurses for Better Patient Care

Adopting a structured and clear clinical handovers can largely reduce any miscommunication about patient that leads to avoidable incidents, says Dr Jack PUN of CityU’s Department of English, after conducting a series of professional development workshops aiming to improve Hong Kong nurses’ handover practices in hospitals. This work has been presented in an article called Training in Communication and Interaction during Shift-to-shift Nursing Handovers in a Bilingual Hospital: A Case Study, and published in the journal of Nurse Education Today.

Clinical handover is a pivotal, high-risk communicative event in hospital. It refers to the transfer of responsibility and accountability between nurses for the continuity of patient care—in hospitals, nurses work in a shift system in order to provide 24/7 continuity of care to patients. Though there are written medical records, shift-to-shift nursing handovers are necessary to provide up-to-date patient’s conditions and important to conduct face-to-face interaction for acute patient care. However, studies have shown that many nursing handovers around the world are unstructured and incomplete, and this ineffective communication can possibly lead to many avoidable incidents such as inappropriate treatments, omission of care, and patient deaths. Thus, effective communication among nurses at handover is therefore critical to the provision of safe and quality healthcare.

To explore the nurses’ perceptions and their actual handover practices, Dr Pun, together with his collaborators, set up an explorative case study in a large hospital in Hong Kong. Using video recordings, actual observations and analysing nurses’ authentic spoken interactions at handovers, his team developed an “evidence-based practice” training module to support 50 frontline nurses for professional development and enhance their quality of nursing handovers. Pre and Post-training interviews and observations were conducted in order to evaluate the changes of their handover practice and the effectiveness of training.

In the training, the nurses learnt about the latest research findings and approaches to effective handover practices and two communication protocols, ISBAR and CARE, which were originally developed in Australia and currently being adapted to use in Hong Kong.

ISBAR concerns the logical sequence for transferring patients information. The five letters stand for Identify (identify the patient and responsible doctor), Situation (explain the patient’s condition), Background (hand over the patient’s medical and social background), Assessment and Action (provide the patient’s clinical condition and state what have been done in the earlier shift), and Recommendation and Readback (explain what have to be done and hand over the accountability to the incoming nurses). CARE, on the other hand, aims at improving the quality of verbal interactions between nurses, by engaging them in active conversation with elements of Connect (greet the team and get prepared for the handover), Ask (ask clarifying questions in each ISBAR stage), Readback (outgoing nurses summarise the information and the incoming nurses acknowledge) and Engage (give active responses and confirm comprehension).

Dr Pun and his team also explained how nurses should use these communication protocols as strategies in response to any possible communication problems identified in video-recorded handovers. A new handover sheet was also developed and validated for changing nurses’ clinical practices in Hong Kong hospital setting. The post-training videos and interviews reveal that the outgoing nurses can transfer their responsibility by covering the information in a predictable sequence according to the ISBAR structure. They confirm if the information conveyed is clear and invite questions from colleagues more frequently. The incoming nurses proactively make queries and check their understanding. The new handover sheet developed by the team in collaboration with nurses at the hospital also provides a proper way to keep a record of previous shift’s work and necessary follow-ups. In sum, the use of the ISBAR and CARE communication protocols and the hospital-based handover sheet in handovers help nurses shift from a passive role to an active role in recognition of their shared responsibility for patient care.

This research is innovative first in its development of new ways to conceptualise and research the communicative complexity of clinical handover. This complexity is captured in the detailed analysis of authentic examples of spoken, written and multimodal communication as this occurs in situ in clinical handovers. Secondly, this “cross-disciplinary” project combines international expertise from both applied linguistics and nursing in deploying ground-breaking and internationally recognised patient safety research. Dr Pun and his team believe only by making research findings accessible to practitioners (ie clinicians and nurses), this "translational approach” in research can generate new knowledge of clinical communication to significantly reduce adverse events and improve patient safety. Establishing and embedding effective communication within health care practices has become a Hong Kong policy imperative. The transfer of knowledge is guaranteed by organising continuous training workshops for hospital nurses, hospital management, clinicians and other health professionals. By promoting evidence-based training in communication, this project will create a safer and more efficient hospital care in Hong Kong.

Dr Pun receives the College’s Excellence in Knowledge Transfer Award 2020 for his project on developing effective clinical communication at nursing handover.

Achievements and publication

External grant received: Developing Effective Nursing Clinical Handover Communication: Improving Patient Safety Experiences and Outcomes Funding body: Professional Services Advancement Support Scheme, Commerce and Economic Development Bureau

Key Publications from this project:

Pun, J., Chan, E.A., Eggins, S. & Slade, D. (2019). Training in communication and interaction during shift-to-shift nursing handovers in a bilingual hospital: A case study. Nursing Education Today. https://doi.org/10.1016/j.nedt.2019.104212

Pun, J., Chan, E.A., Man, M., Eggins, S., Slade, D. (2019). Pre- and post-evaluations of the effects of the Connect, Ask, Respond and Empathise (CARE) protocol on nursing handover: A case study of a bilingual hospital in Hong Kong. Journal of clinical nursing. https://doi.org/10.1111/jocn.14871