Handover Education Research Articles

Non-formal patient handover education for healthcare professionals: a scoping review.

The objective of this scoping review was to identify, organize and present the underpinning learning theories, theoretical frameworks, didactics, content and evaluation methods used in existing literature on non-formal patient handover learning programs for healthcare professionals to highlight existing gaps in evidence. Clinicians are aware that the professional patient handover between healthcare settings poses a safety risk for patients. Learning programs for healthcare professionals improve patient handovers; however, there has been little formal exploration of the content of patient handover learning programs that elicit efficacious, non-formal learning activities. This scoping review therefore sought to investigate the concept of non-formal patient handover learning. This scoping review considered studies that included healthcare professionals from any healthcare profession examining non-formal patient handover learning in a variety of settings. Both qualitative and quantitative studies, as well as conference abstracts and reviews, were considered. An extensive search of multiple databases was undertaken. We considered studies published from 2000 onwards in English, Norwegian, Swedish and Danish. Data extraction was undertaken using an extraction tool developed specifically for this scoping review. The results of the review are presented in narrative form supported by tables. Fourteen studies were included. Study populations mostly comprised nurses or inter-professional groups of healthcare professionals, and non-formal learning program evaluation was performed in the context of intra-hospital handover, handover between hospital and other healthcare settings, and handover in the provision of pre-hospital and emergency services. Non-formal patient handover learning programs lacked reporting on the use of underpinning learning theory. The content of handover learning programs was informed by theoretical frameworks, checklists, mnemonics and frameworks developed based on observations in clinical practice or expert knowledge. Regardless of the type of handover, communication was the most-reported theme. The most-reported didactic was simulation. Pre- and post-intervention evaluation was the most-reported design. Evaluation methods varied from questionnaires and tests to observations and thematic analysis. Outcomes were reported on level 1-3, using Kirkpatrick's hierarchical model. No studies reported on patient outcomes. Gaps in knowledge were identified in the limited number of studies, comprising lack of transparency in the design of patient handover learning programs, notably concerning underpinning learning theories and learning objectives, lack of studies covering multiple settings, lack of knowledge regarding the impact of time on learning, lack of studies of any long-term impact, and lack of studies reporting on patient outcomes. Further research on non-formal handover learning programs is needed to enhance the transparency of program design and coherence in use of educational components from underpinning learning theories to evaluation methods. Few studies manage to document outcomes at the patient level.

A Responsible Educational Handover: Improving Communication to Improve Learning.

An important tenet of competency-based medical education is that the educational continuum should be seamless. The transition from undergraduate medical education (UME) to graduate medical education (GME) is far from seamless, however. Current practices around this transition drive students to focus on appearing to be competitively prepared for residency. A communication at the completion of UME-an educational handover-would encourage students to focus on actually preparing for the care of patients. In April 2018, the American Medical Association's Accelerating Change in Medical Education consortium meeting included a debate and discussion on providing learner performance measures as part of a responsible educational handover from UME to GME. In this Perspective, the authors describe the resulting 5 recommendations for developing such a handover: (1) The purpose of the educational handover should be to provide medical school performance data to guide continued improvement in learner ability and performance, (2) the process used to create an educational handover should be philosophically and practically aligned with the learner's continuous quality improvement, (3) the educational handover should be learner driven with a focus on individualized learning plans that are coproduced by the learner and a coach or advisor, (4) the transfer of information within an educational handover should be done in a standardized format, and (5) together, medical schools and residency programs must invest in adequate infrastructure to support learner improvement. These recommendations are shared to encourage implementation of the educational handover and to generate a potential research agenda that can inform policy and best practices.

Is there a need for formal undergraduate patient handover training and could an educational workshop effectively provide this? A proof-of-concept study in a Scottish Medical School

BackgroundPoor communication between healthcare professionals is recognised as accounting for a significant proportion of adverse patient outcomes. In the UK, the General Medical Council emphasises effective handover (handoff) as an...

Educational Interventions to Improve Handover in Health Care: An Updated Systematic Review.

Effective handovers (handoffs) are vital to patient safety. Medical educators investigated educational interventions to improve handovers in a 2011 systematic review. The number of publications on handover education has increased since then, so authors undertook this updated review. The authors considered studies involving educational interventions to improve handover amongst undergraduate or postgraduate health professionals in acute care settings. In September 2016, two authors independently conducted a standardized search of online databases and completed a data extraction and quality assessment of the articles included. They conducted a content analysis of and extracted key themes from the interventions described. Eighteen reports met the inclusion criteria. All but two were based in the United States. Interventions most commonly involved single-patient exercises based on simulation and role-play. Many studies mentioned multiprofessional education or practice, but interventions occurred largely in single-professional contexts. Analysis of interventions revealed three major themes: facilitating information management, reducing the potential for errors, and improving confidence. The majority of studies assessed Kirkpatrick's outcomes of satisfaction and knowledge/skill improvement (Levels 1 and 2). The strength of conclusions was generally weak. Despite increased interest in and publications on handover, the quality of published research remains poor. Inadequate reporting of interventions, especially as they relate to educational theory, pedagogy, curricula, and resource requirements, continues to impede replication. Weaknesses in methodologies, length of follow-up, and scope of outcomes evaluation (Kirkpatrick levels) persist. Future work to address these issues, and to consider the role of multiprofessional and multiple-patient handovers, is vital.

Focused Training for the Handover of Critical Patient Information During Simulated Pediatric Emergencies.

Miscommunication has been implicated as a leading cause of medical errors, and standardized handover programs have been associated with improved patient outcomes. However, the role of structured handovers in pediatric emergencies remains unclear. We sought to determine if training with an airway, breathing, circulation, situation, background, assessment, recommendation handover tool could improve the transmission of essential patient information during multidisciplinary simulations of critically ill children. We conducted a prospective, randomized, intervention study with first-year pediatric residents at a quaternary academic children's hospital. Baseline and second handovers were recorded for residents in the intervention group (n = 12) and residents in the control group (n = 8) during multidisciplinary simulations throughout the academic year. The intervention group received handover education after baseline handover observation and a cognitive aid before second handover observation. Audio-recorded handovers were scored by using a Delphi-developed assessment tool by a blinded rater. There was no difference in baseline handover scores between groups (P = .69), but second handover scores were significantly higher in the intervention group (median 12.5 [interquartile range 12-13] versus median 7.5 [interquartile range 6-8] in the control group; P < .01). Trained residents were more likely to include a reason for the call (P < .01), focused history (P = .02), and summative assessment (P = .03). Neither timing of the second observation in the academic year nor duration between first and second observation were associated with the second handover scores (both P > .5). Structured handover training and provision of a cognitive aid may improve the inclusion of essential patient information in the handover of simulated critically ill children.

Program Directors’ Perceptions of a Post-Match Competency Handover Between Medical School and Residency

An educational handover at the completion of medical school that transmits competency information about individual learners has been proposed as a means for improving the sub-optimal communication between medical school and residency. The authors created an Accreditation Council for Graduate Medical Education (ACGME) milestones handover (MH) for graduating medical students entering surgery, pediatrics, and OBGYN residencies utilizing assessments primarily from residency preparatory courses. This pilot study investigated residency program directors’ (PDs) perspectives on the potential utility of the MH. The authors mapped medical school assessment data to the specialty-specific ACGME level one milestones for 39 graduating medical students. The MH reported whether the student had met the level one milestone competencies. After the residency match, the MH was sent to PDs with an electronic survey asking about their perceptions of the handover. The MHs reported level one competency determinations for most of the ACGME milestones (12 of 16 for surgery, 26 of 28 for OBGYN, and 18 of 21 milestones for pediatrics). Of the 38 surveyed PDs, 25 (66%) responded. PDs reported that the MH provided better level one competency information for new trainees compared to the Medical Student Performance Evaluation [Likert score 2.07 (SD 1.16) vs. 3.67 (SD 1.14), P < 0.05] however did not feel that it was superior in describing the attributes of a new intern [Likert score 3.32 (SD 0.95) vs. 3.68 (SD 0.95), P = 0.09]. This preliminary data suggests that the MH could be a potentially useful tool. Further work will need to expand these efforts to improve the generalizability and validity evidence of a competency-based educational handover between medical school and residency.

Responsible Milestone-Based Educational Handover With Individualized Learning Plan From Undergraduate to Graduate Pediatric Medical Education

Communication of medical students' pediatric milestone assessments and individual learning plans from medical schools to pediatric residency directors allows for effective educational handovers promoting the continuum of education. Existing undergraduate medical education assessments can provide meaningful data to determine most pediatric milestone levels.

Influence of learner knowledge and case complexity on handover accuracy and cognitive load: results from a simulation study.

The handover represents a high-risk event in which errors are common and lead to patient harm. A better understanding of the cognitive mechanisms of handover errors is essential to improving handover education and practice. This paper reports on an experiment conducted to study the effects of learner knowledge, case complexity (i.e. cases with or without a clear diagnosis) and their interaction on handover accuracy and cognitive load. Participants were 52 Dutch medical students in Years 2 and 6. The experiment employed a repeated-measures design with two explanatory variables: case complexity (simple or complex) as the within-subject variable, and learner knowledge (as indicated by illness script maturity) as the between-subject covariate. The dependent variables were handover accuracy and cognitive load. Each participant performed a total of four simulated handovers involving two simple cases and two complex cases. Higher illness script maturity predicted increased handover accuracy (p<0.001) and lower cognitive load (p=0.007). Case complexity did not independently affect either outcome. For handover accuracy, there was no interaction between case complexity and illness script maturity. For cognitive load, there was an interaction effect between illness script maturity and case complexity, indicating that more mature illness scripts reduced cognitive load less in complex cases than in simple cases. Students with more mature illness scripts performed more accurate handovers and experienced lower cognitive load. For cognitive load, these effects were more pronounced in simple than complex cases. If replicated, these findings suggest that handover curricula and protocols should provide support that varies according to the knowledge of the trainee.

Bridging the Continuum: Lessons Learned from Creating a Competency-Based Educational Handover in Obstetrics and Gynecology

The true adoption of Competency-Based Medical Education (CBME) should allow for information about individual learners to be fed forward from Undergraduate Medical Education (UME) to Graduate Medical Education (GME). An obstetrics and gynecology residency preparation elective for senior medical students was utilized to create a milestone-based educational handover that reported individual learner performance for 25 of the 28 level one milestones. The authors describe the process and the questions that arose about the implications of reporting competency-based information for learners of all levels. The authors posit that CBME will be a transformative shift only if barriers of communication can be broken down between UME and GME.

Reporting Achievement of Medical Student Milestones to Residency Program Directors: An Educational Handover.

Competency-based education, including assessment of specialty-specific milestones, has become the dominant medical education paradigm; however, how to determine baseline competency of entering interns is unclear-as is to whom this responsibility falls. Medical schools should take responsibility for providing residency programs with accurate, competency-based assessments of their graduates. A University of Michigan ad hoc committee developed (spring 2013) a post-Match, milestone-based medical student performance evaluation for seven students matched into emergency medicine (EM) residencies. The committee determined EM milestone levels for each student based on assessments from the EM clerkship, end-of-third-year multistation standardized patient exam, EM boot camp elective, and other medical school data. In this feasibility study, the committee assessed nearly all 23 EM milestones for all seven graduates, shared these performance evaluations with the program director (PD) where each student matched, and subsequently surveyed the PDs regarding this pilot. Of the five responding PDs, none reported using the traditional medical student performance evaluation to customize training, four (80%) indicated that the proposed assessment provided novel information, and 100% answered that the assessment would be useful for all incoming trainees. An EM milestone-based, post-Match assessment that uses existing assessment data is feasible and may be effective for communicating competency-based information about medical school graduates to receiving residency programs. Next steps include further aligning assessments with competencies, determining the benefit of such an assessment for other specialties, and articulating the national need for an effective educational handover tool between undergraduate and graduate medical education institutions.

P078: Handover education in Canadian adult and pediatric emergency medicine residencies: a national survey and needs assessment

Introduction: Emergency department handover is a high-risk period for patient safety. A recent study showed a decreased rate of preventable adverse events and errors after implementation of a resident hand-off bundle on pediatric inpatient wards. In a 2013 survey by the Canadian Associations of Internes and Residents, only 11% of residents in any discipline stated they received a formal teaching session on handover. Recently, the CanMEDS 2015 Physician Competency Framework has added safe and skillful transfer of patient care as a new proficiency within the collaborator role. We hypothesize that significant variation exists in the current delivery and evaluation of handover education in Canadian EM residencies. Methods: We conducted a descriptive, cross-sectional survey of Canadian residents enrolled in the three main training streams of Emergency Medicine (FRCP CCFP-EM, PEM). The primary outcome was to determine which educational modalities are used to teach and assess handover proficiency. Secondarily, we described current sign-over practices and perceived competency at patient handover. Results: 130 residents completed the survey (73% FRCP, 19% CCFP-EM, 8% PEM). 6% of residents were aware of handover proficiency objectives within their curriculum, while 15% acknowledged formal evaluation in this area. 98% of respondents were taught handover by observation of staff or residents on shift, while 55% had direct teaching on the job. Less than 10% of respondents received formal sessions in didactic lecture, small group or simulation formats. Evaluation of handover skills occurred primarily by on shift observation (100% of respondents), while 3% of residents had received assessment through simulation. Local centre handover practices were variable; less than half of residents used mnemonic tools, written or electronic adjuncts. Conclusion: Canadian EM residents receive variable and sparse formal training and assessment on emergency department handover. The majority of training occurs by on shift observation and few trainees receive instruction on objective tools or explicit patient care standards. There exists potential for further development of standardized objectives, utilization of other educational modalities and formal assessments to better prepare residents to conduct safer patient handoffs.

Handover education improves skill and confidence.

Despite the frequency of patient-care handovers and vulnerability to errors, medical schools infrequently teach handover skills. Our study evaluated the impact of a medical school handover curriculum on students' performance, as rated by faculty members, peers and self-assessment. Nineteen fourth-year medical students participated in a handover curriculum that included a workshop and three directly observed patient handovers, with feedback from faculty members. Multivariate repeated-measures analysis evaluated faculty member, peer, and self-rated performance over time. Students' self-assessed confidence in performing handovers prior to, at the end of, and 8-12months after the curriculum was also analysed. Faculty member, peer and self-assessments showed that students' performance significantly improved after the curriculum, on handover content, clinical judgment and overall performance (p<0.05). Students rated the curriculum as effective and characterised themselves as more prepared to perform handovers, with these findings persisting for 8-12months (p≤0.001). Medical schools infrequently teach handover skills DISCUSSION: A handover curriculum appears to improve medical students' handover performance, as evaluated by independent ratings from faculty members, peers and the students themselves, in addition to improving the students' confidence.

G531(P) Improving the safety and quality of handover

Context This project aimed to improve handover for paediatric medical specialties, paediatric surgery and general paediatrics at a regional tertiary paediatric centre. As well as doctors of varying grade and specialty, others involved include the nursing outreach team and bed manager. Problem Handover occurs three times a day and with 50–80 complex patients it needs to be an efficient process ensuring patient safety and communication of essential appropriate information. Issues around the quality and safety of handover were highlighted from clinicians within the department, trainee feedback and the GMC survey. Assessment of problem and analysis of its causes Baseline measurements were obtained over 16 consecutive handovers. Measures included: start time, length of handover, number of bleep interruptions, time of specialty handover, and missed patients. Problems identified included: Late specialty handovers resulting in delays to commencing shifts Frequent non-urgent bleeps interrupting flow and causing distraction Patients not handed over in order meaning patients ‘missed’ Multiple late ‘corridor handovers’ These findings were presented to different stakeholders to address concerns, identify good practice and suggest areas for improvement. Suggestions included; introduction of a handover checklist, reminders on ward phones of protected handover times, and the introduction of a traffic light system to classify patients into an acuity category. Intervention Utilising small tests of change (PDSA cycles) we implemented sequential changes. For example a handover checklist was introduced at the start of each handover. Simple additions such as shutting the door gave clear non-verbal clues to people who were late. Stratifying patients according to traffic light acuity red (un-stable) amber (potentially unstable) and green (stable and on pathway) helped keep handovers focused. Strategy for change These changes were introduced and measured over an additional 16 handovers with continual feedback from junior doctors and outreach nurses. The consultant body was kept informed by the project lead. Measurement of improvement Measurements were undertaken over specific periods rather than continually. The project began in the quieter summer months with lower total patient numbers and the 3 rd data collection is from November during busier times on the unit. Effects of changes Several small changes have considerably improved the handover process. Verbal feedback has been really positive. Some of the initial changes have now been incorporated into the trust-wide computer system and are now used routinely in adult practice. We are continuing to measure variables and make changes. Uptake of some of the changes is variable (see results, Table 1), however as we reinforce successful changes and introduce handover education into induction, we hope to make adjustments standard procedure. Next steps are to develop a standardised structure for handover of patients according to acuity category. This will be linked to need for review and outreach involvement. Lessons learnt Getting buy-in from the consultant body and key stakeholders has been paramount. The senior lead empowering the juniors who are present on a daily basis to continue change when faced with those less willing to engage in a new process has been essential to success. Using regular feedback has enabled us to review improvements. We have been able to re-adjust changes on a short time scale, enabling us to reflect on the impact of our adjustments on the safety of handover. Message for others Simple rapid small changes have significantly improved the efficiency and safety of handover. Front line junior staff, empowered by more senior clinicians, have introduced these changes. Engaging the whole team is critical to sustained success. Change is a continual dynamic process and monitoring effects of interventions helps identify where further work is needed.

Multicenter development, implementation, and patient safety impacts of a simulation-based module to teach handovers to pediatric residents.

Teaching and evaluation of handovers are important requirements of graduate medical education (GME), but well-defined and effective methods have not been clearly established. Case-based computer simulations provide potential methods to teach, evaluate, and practice handovers. Case-based computer simulation modules were developed. In these modules, trainees care for a virtual patient in a time-lapsed session, followed by real-time synthesis and handover of the clinical information to a partner who uses this information to continue caring for the same patient in a simulated night scenario, with an observer tallying included handover components. The process culminates with evaluator feedback and structured handover education. Surveys were used before and after module implementation to allow the interns to rate the quality of handover provided and record rapid responses and transfers to the ICU. Fifty-two pediatric and medicine/pediatric residents from 2 institutions participated in the modules. "Anticipatory guidance" elements of the handover were the most frequently excluded (missing at least 1 component in 77% of module handovers). There were no significant differences in the proportion of nights with rapid response calls (7.24% vs 12.79%, P=.052) or transfers to the ICU (7.76% vs 11.27%, P=.21) before and after module implementation. Case-based, computer-simulation modules are an easily implemented and generalizable mechanism for handover education and assessment. Although significant improvements in patient safety outcomes were not seen as a result of the educational module alone, novel techniques of this nature may supplement handover bundles that have been demonstrated to improve patient safety.

Pediatric Residency Program Handover: Before and After the ACGME Requirement

ObjectiveTo determine what changes occurred in pediatric residency programs with regards to handover education and assessment before and after the Accreditation Council for Graduate Medical Education (ACGME) requirement mandating monitoring safe handover practices in July 2011. MethodsWe sent surveys at 2 time periods to all pediatric program directors in the United States, as identified from a list provided by the Association of Pediatric Program Directors. Respondents were asked about their program demographics, whether they had handover curricula, how trainees were taught to perform handovers, and perceived barriers to effective handover. ResultsResponse rates were 58% in both survey years. After the ACGME requirement, only 1 of 3 of programs reported a handover curriculum with goals, objectives, and assessment tools. There was a statistically significant increase in the percentage of those responding that resident handover education primarily occurred by role modeling (66% vs 82%; P < .05). Other learners (visiting residents, medical students) also continued to learn handover skills by role modeling (55% vs 56%; P = NS). Lack of feedback and interruptions were recognized as barriers to successful handover by program directors in both survey years. ConclusionsThere is a continued need for handover curricula with didactic and practical components as well as assessment pieces within pediatric residency programs. Barriers to effective handover such as lack of feedback and interruptions continue to be major problems. There is a lack of faculty ownership and interest in learner handover that may affect long-term successes. Because role modeling continues to be the main way in which trainees learn handover, specific attention should be given to teach role-modeling techniques.

Improving hospital weekend handover: a user-centered, standardised approach.

Clinical Handover remains one of the most perilous procedures in medicine (1). Weekend handover has emerged as a key area of concern with high variability in handover processes across hospitals (1,2,4, 5–10).Studying weekend handover processes within medicine at an acute teaching hospital revealed huge variability in documented content and structure. A total of 12 different pro formas were in use by the medical day-team to handover to the weekend team on-call. A Likert-survey of doctors revealed 93% felt the current handover system needed improvement with 71% stating that it did not ensure patient safety (Chi-squared, p-value <0.001, n=32). Semi-structured interviews of doctors identified common themes including “a lack of consistency in approach” “poor standardization” and “high variability”.Seeking to address concerns of standardization, a standardized handover pro forma was developed using Royal College of Physician (RCP) guidelines (2), with direct end-user input. Results following implementation revealed a considerable improvement in documented ceiling of care, urgency of task and team member assignment with 100% uptake of the new proforma at both 4-week and 6-month post-implementation analyses. 88% of doctors surveyed perceived that the new proforma improved patient safety (p<0.01, n=25), with 62% highlighting that it allowed doctors to work more efficiently. Results also revealed that 44% felt further improvements were needed and highlighted electronic solutions and handover training as main priorities.Handover briefing was subsequently incorporated into junior doctor induction and education modules delivered, with good feedback. Following collaboration with key stakeholders and with end-user input, integrated electronic handover software was designed and funding secured. The software is currently under final development.Introducing a standardized handover proforma can be an effective initial step in improving weekend handover. Handover education and end-user involvement are key in improving the process. Electronic handover solutions have been shown to significantly increase the quality of handover and are worth considering (9, 10).

Hand-Overs in Pediatric Residency Programs

In July 2012, the ACGME stated that pediatric residency programs must ensure and monitor effective, structured hand-over processes. Our aim was to examine if changes had occurred from 2011 to 2012 with regards to pediatric programs' implementation of hand-over education, feedback and barriers to effective hand-overs.

Teaching handover of care to medical students

Handover is a key activity in acute health care, with patient safety implications if it is not performed well. This is becoming more important with shorter working hours and therefore a greater number of handovers. Despite this there is a paucity of evidence to guide education to enhance practice. A teaching session for senior medical students on handover of care was devised, delivered and evaluated, with the aim of producing a theoretically sound intervention that is acceptable to students and can be delivered with limited resources. Teaching sessions to improve the handover of care have been described before, but the descriptions lacked the detail to allow a reader to deliver the session as intended. We designed and delivered a 1-hour session on handover for senior medical students. This was based on models of handover practice and education, and was based on broader patient safety education principles. Student satisfaction was high and students rated their knowledge as having improved. No funding and minimal resources were used to develop and deliver the teaching session. A pedagogically sound teaching session, based on best-evidence theories for modelling handover practice, is presented. The perceived ability to handover has also been extremely high after the intervention. Other educators can use this intervention as a starting point for designing interventions within their own setting, and to allow future research to investigate the effectiveness of such interventions.

Clinical handover in acute psychiatric and community mental health settings

This study collected an area-wide snapshot of current handover practice in psychiatric settings which included acute care units and community mental health centres. The study was conducted in two stages. Firstly, a questionnaire was sent to all clinical mental health staff within an area-wide health service regarding normal handover procedures and processes. The second part of the study used non-participant observers to evaluate actual handovers in inpatient and community settings. Of the 1125 surveys distributed in stage one, 380 (34%) were returned completed. Of the 40 handovers observed in stage two in which 637 patients were discussed, 40% included at least one consultant psychiatrist or registrar as a participant. Almost all the handovers were completed face-to-face in a specific location with a set time and duration. Eighty-six per cent of respondents reported that deteriorating patients were escalated for rapid response. The results of the survey and structured observations support the issues emerging from the literature from medical, surgical and clinical team handovers. Additionally, the issue of identifiers for deterioration of a psychiatric patient emerged as an area worthy of further investigation and incorporation into clinical handover education and training for psychiatric services.