Care Delivery

The safe transfer of care is a vital component of the quality of care and safe practice (Pothier, Monteiro, Nooktlar et al, 2005). Handovers have been identified as ???error hotspots??™. All handovers may be error prone including those between individuals from the same or different professional groups, between departments and between sectors of care (Bruce Bayley, et al, 2005). When the process of handover is inadequately undertaken risks to the patient are increased and may subsequently lead to harm (BMA, 2005; Joint Commission, 2007). Patients are no longer cared for by just nurses and doctors; multiple healthcare professionals now contribute to the care of patients which increases the need for robust mechanisms for handover of care (RCN, 2008). BMA (2004) state Continuity of care now means team responsibility for care as well as individual responsibility.
Information regarding patients must be transferred from shift to shift to provide continuity and consistent patient care (Hoban, 2003). Handovers occur on all wards and have been described as a religious rite (Scovell, 2010). Currie (2002) identified one common feature of all handovers: the quality of the handover effects the provision of nursing care in the subsequent shift. Scovell (2010) argues that quality is important but there are unanswered questions about whether this involves the content or the structure of the handover and if there are any variables during the handover process that affect quality.
Best practice will be explored by reviewing literature regarding nursing handovers. There are three themes that have emerged; patient safety, patient confidentiality and patient participation for continuity of care. These themes will be explored to enable professional and managerial development in this area of care. The new found knowledge will be used in future and disseminated to colleagues and patients to ensure safe and effective nursing practice.

Patient Safety
The NMC (2008) urges nurses to work within a team to monitor the quality of care delivered and maintain the safety of the patient within their care. The Code (2008) states that all nurses ???must work with others to protect and promote health and wellbeing of patients in a nurses care??™. Seddon (2007, cited by Wallis, 2010) suggests that bedside handover can promote patient safety due to the ability to observe equipment, medications and intravenous lines whilst discussing the patient. the information that should be shared on handover should consist of the patients health condition, any relevant changes, medications, ongoing treatment, tests, examinations and any possible complications that may arise (WHO, 2007). Personal experiences have shown vital information being incorrect or missed on handovers putting patients safety at risk. An ineffective handover can contribute to patients falling through gaps in the system. Failures relating to patient safety include medication errors and patient deaths as found by Friesen et al (2008). Friesen et al (2008) states that 66% of medications errors occur during handover to other healthcare teams due to ineffective communication. Ineffective communication in healthcare settings is recognised by the NHS Institute for Innovation and Improvement (2013) as being the most common cause of organisational and clinical errors.
McMurray (2009) discovered nurses that worked different shifts, for example, short shifts, found they were not receiving as much information due to not arriving on shift at the same time as other nurses. They often receive rushed handovers and are misinformed of patient care; therefore putting patients at risk.
Kassean and Jagoo (2005) found that office based handovers consist of one way communication from the previous nurse in charge. This method was found to lack individual important information, patient care planning and whether actions had been documented throughout the shift as the notes could not be accessed during handover. Without the patients notes being present at handover, important information could be miss and the patients care could be compromised. From an organisational view, office based handovers appear to be time consuming and decreases the numbers of staff left on the ward for long periods of time meaning patients care could suffer (Avon and Wiltshire Trust, 2012). Personal experiences of office based handovers has concurred with this view of being time consuming; many irrelevant questions and discussions can occur as well as interruptions from staff on the ward needing assistance.
Sexton et al (2004) found that taped handovers nurses could be long winded with their information and foreign accents were often problematic. This could cause confusion putting patient safety at risk. Others problems identified with tape recorded handovers include nurses found to be nervous speaking into a tape recorder leading to rush the handover; the chance that the tape could be misplaced, breaching confidentiality and running the risk of having no information on patients; and no handover structure or education, increasing the chance of irrelevant information being shared. Positive patient safety aspects of taped handovers were hard to find which is reflected by the lack of information. However in the right situation it is possible for this method of handover to be successful.
To ensure best practice is incorporated into handovers a framework should be used to structure the information given. The most commonly referenced and recommended framework for handover structure is the SBAR Framework. SBAR is an acronym for Situation, Background, Assessment and Recommendations. SBAR was developed to improve incidence of harm to patients (NHS Institute for Innovation and Improvement, 2008). The use of SBAR during handover improves the efficiency of communication and allows all members of the team lower down the hierarchy to contribute to conversation in an organised fashion (The Royal College of Obstetricians and Gynaecologists, 2010) and acts as a mechanism to frame conversations which require clinician??™s attention and immediate action. Research has identified that with the use of a framework, all of the information to enable patient safety is delivered (NHS, 2008). SBAR enables clarification of which information should be communicated between the team whilst developing teamwork and concentrating on patient safety (NHS Institute for Innovation and Improvement, 2013). Without the use of a framework to structure a handover, important clinical information could be missed putting patients at risk. As a student and qualified nurse, patient information can be prepared using a pre-prepared handover sheet such as, SBAR, to ensure all key points are covered and aiding prevention of patient morbidity and mortality.

Patient Confidentiality
Currie (2002) states that handovers should maintain confidentiality by ensuring information cannot be overheard, notes remain with you at all times and shredded at the end of the shift. Notes are not to be taken out of the clinical area and must not become part of the patients case notes. The British Medical Association also agree with this stating patients expect their confidentiality to be respected in handling personal information. Confidentiality is a legal obligation derived from case law which is a major aspect of The Code (2008), failure to comply with confidentially is not best practice and the nurse may be deemed unfit to practice. The Scottish Ombudsman (2010) reported communication and confidentiality to be high in complaints within the NHS. There are difficulties maintaining confidentiality during handover, especially bedside handover (Cahill, 1998). Casey et al (2011) states that nurses respect patient confidentiality, which is required by law, however it is frequently overlooked in busy care settings where they forget to take care when providing patient information. Nurses need always be aware of infringement of a patients personal space and identify factors that could lead to a breach of confidentiality (Erlen, 1998, cited by Messam and Pettifer, 2009). Office based handover has been observed through nurse training and it does promote confidentiality but lacks patient involvement. Office based handover can also allow nurses to give opinions of their patients in confidence (Kelly, 2005). Taped handover promotes confidentially as long as they are listened to in privatebut they are a one way process of information exchange (Dowding, 2001).
Scovell (2010) argues that bedside handover can breach patient confidentiality. Usually curtains are pulled around the patients bed during handover which are not soundproof therefore nurses do not want to vocalize sensitive but relevant information in case it is heard by another patient. Bedside handover would not breach confidentiality if the patient was in a side room with a closed door.

Patient Participation for Continuity of Care
Patient participation during handover is considered an important aspect of patient centred care; patients are able to become involved and have their say in their own care (McMurray, Chaboyer and Wallis, 2009). Fink, Hesselink and Pijenbork et al (2012) discovered patients preferred handover of care ensured communication between healthcare professional is clear and unambiguous; this ensures continuity of care and a responsibility for the patients wellbeing. Kings College London (2012) states that bedside handover supports communication between healthcare professionals and patients regarding patient progress whilst providing an opportunity to take their own decisions. However, barriers have been identified which stop patients participating with their own handover; the use of technical language or ???jargon??™ between healthcare professionals has been found to confuse patients (Helleso, 2006), the belief that patients are to unwell or not confident enough to participate (Cahill, 1998) and issues regarding patient confidentiality (Hopkinson, 2002).
The importance of patient participation and the provision of timely and appropriate information are identified in the literature as a solution to improving the handover of patient to healthcare professionals (McKenna, Keeney, Glenn A et al, 2000). However, Coulter (2006) identified that patients did not feel involved in decisions about their care; even though patient??™s expectations in this area continue to rise many nurses and healthcare professionals are failing to make the necessary adjustments to their practice to ensure patients do not falls through the gaps in provision. Handovers between healthcare settings is highlighted as a problem; with patients reporting that handovers were not co-ordinated effectively (Coulter, 2006). The need to work in partnership with patients, carers and families in decision making is highlighted to ensure continuity of care. Coulter (2006) argues that patients perceive healthcare is governed in a paternalistic approach; which offers little opportunity to express their preferences or influence decisions about their care. Sometimes the attempt to involve patients in their care is ???mere tokensim??™ (Cahill, 1998) as a group of nurses gather at the end of the bed ignoring the patient (Scovell, 2010). Philpin (2006) discovered that nurses lower their voices sufficiently to make it difficult for the awake and alert patient to hear what is being said unless a positive event is being discussed, in which case the nurse is more likely to deliberately involve the patient.
Manias and Street (2000) suggest that bedside handover is an ???examination??™ where greater emphasis is placed on the appearance of the bed rather than the patient patients physical or psychological state. The nurse from the outgoing shift may prioritise defense of their actions explain how busy the shift has been, rather than discussing the treatment and condition of the patient.
Positive outcomes of bedside handover have been identified by Anderson and Magino (2006). This study revealed financial savings of hundreds of hours of overtime due to bedside handovers taking less time to complete than other handovers. This study also identified improved views from patients about being involved in their care. Since then the Department of Health (DH, 2012) have produced the document ???Liberating the NHS, no decision about me without me??™. This document aims to provide the patient the opportunity to make their own decisions, understanding their preferences, aspirations and having correct information to make informed decisions that is supported by healthcare professionals.
Handover can take place in the ward office, having positive and negative effects. Confidentiality is promoted and the privacy allows nurses to make subjective statements (Kelly, 2005). If effective leadership is absent excessive time may be spent sharing irrelevant information (Sexton et al, 2004), the report may go on for longer than necessary costing the NHS money and staff hours and depriving patients of care. The privacy of the office allows thorough explanation of any or all relevant details concerning the patient??™s social situation (Scovell, 2010). Office based handover is also a place for non patient specific roles of handover; such as, support, cathartic debriefing, peer assessment and motivation (Scovell, 2010). However, the ward office is not free from interruptions. The main reason for dissatisfaction with nursing handovers is frequent disturbance (Meissner et al, 2007).
Taped handover was initiated to lessen shift overlap time (Prouse, 1995) and reduce the use of financial resources (Burke, 1999). The concern regarding taped handover is the quality of content being recorded due to the nurses ability to give concise and relevant information (Prouse, 1995). However, taped handover avoids interruption problems with use of the pause button (Mckenna, 1997). The information can also be started again at any later time although Kerr (2002) states that there is a reluctance to stop the tape for any reason. A taped handover lacks nurse to nurse input and does not involve the patient at all due to the recording taking place in private. Any questions raised regarding the patient could remain unanswered if the nurse has let the ward and not included all relevant information (Kerr, 2002). The oncoming nurse could consult patient??™s notes for answers but this is time consuming. Social cohesiveness and emotional catharsis cannot be fulfilled during taped handover (Scovell, 2010) where the emotional fatigue can be ???given away??™ and not carried home when going off duty (Philpin, 2006). Kerr (2002) and Hopkinson (2002) also believe taped handovers provide a ???low level of supportive functions??™ which undermine emotional support. Scovell (20100 argues that taped handover solves the problem of nurses not being ready to handover when oncoming nurses arrive resulting in delays and using time that could be used on patients.

Management is a fundamental aspect of care. The five essential managerial functions are planning, control, co-ordination, directing, leading, and controlling (Koontz and O??™Donnell, 1984). Nurses must have knowledge relating to planning, control and co-ordination due to the large number of healthcare professionals involve with each patients care and the multitude of tasks. Co-ordination, directing, leading and control are important in safe delegation and leadership within the ward setting. Failure to perform these tasks could have a detrimental effect on patients care. In relation to handover, a nurses duty is to adapt their knowledge skills and attitude to ensure best evidenced based practice when giving and receiving handover.
Is has become apparent that the three types of handovers have their positives and negatives depending on which healthcare setting they are applied to. Bedside handovers promote patient involvement and safety but breach confidentiality in many cases. Office based and taped handovers promote confidentiality but can lack involvement and safety aspects. The personal preferred handover is bedside due to the involvement and feedback that is received; however to ensure confidentiality, bedside handovers would need to be scheduled which could incur delays. The location of handover delineates a certain extent on what information can be discussed therefore a private room is essential for confidentiality but not practical. In order to improve handover, Meissner et al (2007) suggest that leadership is the quality needed. For example, ward manager could organize staff to handover at the correct time whilst recognizing the importance of their colleagues and their own clinical input. Organistaion of meal breaks so that they do no coincide with handover and designating a nurse to direct auxiliary staff to prevent interruptions are other examples (Scovell, 2010). Lack of important information to enable care planning can be problematic, therefore handovers should be structured, Sexton et al (2004) suggest that??™s guidelines or teaching initiatives should prescribe what is needed for an effective handover. The use of SBAR in all handovers will help to produce effective transfer of knowledge. A clear format should be devised for each healthcare setting depending on their area of expertise and patients. The format would differ from each area but the main aim is the wellbeing of the patients in their care.
Student nurses learn the aspects of handover whilst in placement. Handover is firstly observed and as a senior student a qualified nurse you are expected to give handover. Once qualified, nurses learn to adapt to the ward culture and learn that they are important aspects of handover. Too often handover is undermined and seen as pointless to the detriment of colleagues and patients.