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NSW Nurses and Midwives’ Association

Professional issues | 3

Do not disturb Findings from the NSWNMA nursing handover survey

Do not disturb Findings from the NSWNMA nursing handover survey

Contents Who we are

3

Introduction 5 The purpose of nursing handover

6

Handover format

8

Missed opportunities in the nursing handover

10

Third-person handover

12

Bedside handover

14

Handover errors

18

Unsafe handover – contributory factors

22

A call for governance

25

Conclusion 28 References 29

NSW Nurses and Midwives’ Association

Professional issues | 3

Who we are The New South Wales Nurses and Midwives’ Association (NSWNMA) is the registered union for all nurses and midwives in New South Wales. The membership of the NSWNMA is comprised of those who perform nursing and midwifery work at all levels, including management and education. This includes registered nurses and midwives, enrolled nurses and assistants in nursing (who are unregulated).

The NSWNMA has approximately 64,000 members and 7000 associate members. Eligible members of the NSWNMA are also deemed to be members of the New South Wales Branch of the Australian Nursing and Midwifery Federation.

Our role is to protect and advance the interests of nurses and midwives and the nursing and midwifery professions. We are also committed to improving standards of patient care and the quality of services in health and aged care services.

This report is authorised by Brett Holmes of the New South Wales Nurses and Midwives’ Association

Contact details NSW Nurses and Midwives’ Association Australian Nursing and Midwifery Federation NSW Branch 50 O’Dea Avenue Waterloo, NSW 2017

P (02) 8595 1234 (metro) 1300 367 962 (rural) E gensec@nswnma.asn.au

3

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Introduction In 2016, the NSWNMA conducted a member survey about current practice and experience in relation to the nursing handover. In some healthcare settings the nursing handover process is being eroded as a cost saving exercise, raising concerns about safe, quality care. It is hoped this report will provide an evidence-based rationale for the retention of a paid nursing handover and assist in the development of safe clinical practice.

Questions were designed to elicit responses related to handover between shifts rather than handing over information to an external agency (eg. GP or Ambulance service). 1185 responses were received over a six-week period. 70% came from registered nurses and midwives, approximately 12% from enrolled nurses, 9% from assistants in nursing (AINs, however titled). In addition, a number of members identified themselves as nurse managers, nurse educators and specialist nurse practitioners.

Approximately 60% of responses came from staff working in the public health system, 20% from residential aged care facilities, 12% from private hospitals and the remainder from community based services and related services such as education, defence services and child and family services. Those who completed the survey are collectively referred to as ‘nurses’ throughout this report – this is not intended to devalue the roles of other nursing classifications, such as midwives or nurse educators.

The terms ‘nursing handover’ and ‘clinical handover’ are often used to describe the same process. In the context of this report the term ‘nursing handover’ is used to reflect the membership base of the NSWNMA.

Key recommendations

1 Governance of the nursing handover should be enhanced in all healthcare settings to ensure: • Clinical leadership of the process • Consistent handover guidelines that are well communicated and understood • Handover remains structured, relevant, focused and timely, with minimal interruption • Collaborative multi-disciplinary working is promoted • A handover champion is available in each health care workplace • Education of nurses in relation to core purpose and delivery of information.

2 Nursing handover must be recognised by employers as an integral part of the span of duty and included as part of contracted hours.

3 The nursing handover within community based services and residential aged care requires urgent attention to ensure the recommendations of The Garling Report5 are transferred.

4 Clear competencies in relation to nursing handover and further research to establish how nurse education can prepare nurses to provide effective handover should be developed.

5 The practical experience of both giving and receiving a supervised handover should be a consistent mandatory element of nurse education to ensure all new graduates have the skills and competency required to deliver a safe and effective nursing handover.

6 Residential aged care providers should ensure that all staff delivering healthcare receive a formal nursing handover, including assistants in nursing (however titled).

7 Caution should be applied to the implementation of third person handovers until a sound evidence base is established in relation to their ability to ensure safe practice.

5

The purpose of nursing handover

Âą95%

of nurses said they received a handover as part of their normal span of duty

Nurses work within a relational framework in which communication is essential. As much as 80% of working time is spent communicating, with three quarters being spent on talking alone1, so it is unsurprising that failures in communication are ranked as the most common cause of poor practice2.

Breakdown in communication or information transfer has been identified as a major causal factor in adverse events3, which has led to nursing handover being classed as a high risk event4. Following a series of failings in public healthcare services, a Special Commission Inquiry headed by Peter Garling SC was established to investigate causal factors. The findings were released as The Garling Report in 20085. One of the recommendations for safer practice was that all NSW health facilities have a robust nursing handover policy.

The following year a series of key principles for safe handover was introduced in NSW public health settings, which recognised handover as an essential part of nurses’ daily work. The

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90%

said this occurred at the start of their duty before any contact with patients/clients

principles promoted user engagement, ensured value was given to the nursing handover and highlighted the importance of leadership in this area6. In support, the Australian Commission on Safety and Quality in Health Care developed a Guide to Clinical Handover Improvement3 aimed at enhancing governance of the nursing handover.

There is little doubt that nurses and care recipients have benefited from enhanced protections around the transfer of information.

In our survey, almost 95% of nurses said they received a handover as part of their normal span of duty. 90% said this occurred at the start of their span of duty before any contact was made with patients/clients, or as patients were received into a clinical area following transfer for ongoing or episodic care. This is consistent with the belief that the key role of the nursing handover is not just to exchange keys and complete a span of duty, but to transfer professional responsibility for the care of patients.

The following definition of nursing (or clinical) handover has been internationally recognised and is consistent with our findings: “The transfer of professional responsibility and accountability for some or all aspects of care for a patient or group of patients to another person or professional group on a temporary or permanent basis� 7 The principle intention of handover is to share patient information8 and an effective exchange of information is essential to maintain safe patient care8,9,10,11. The value that nurses place on giving and receiving handover means that it often occurs in their own time through staying late or arriving early for shifts12.

This is not conducive to safe information transfer as the process becomes rushed and exception reporting more prevalent.

Previous research identified that nurses receiving handover experience it differently

from those giving it14,15, with those receiving being less satisfied with the process than those delivering the information13. Those receiving handover prefer more information, longer handover time and the opportunity to ask more questions, whereas those leaving shift prefer a shorter duration and less eye contact14.

This may be due more to the transfer of professional responsibility than purely the transfer of information4. Nurses giving handover may experience relief at transferring accountability for the shift to the incoming nurse, whereas the nurse receiving the information may naturally seek more clarity and require more information to feel comfortable accepting professional responsibility.

Therefore, it is essential that nurses receive adequate paid time at the beginning and end of a span of duty so that the professional exchange is not compromised.

7

Handover format What method is used to deliver handover?

41.62%

Verbal – face-to-face

Tape recorded

0.09% 29.67%

Bedside

Written

1.05%

Combination (ie: verbal & written; taped & written)

17.98%

Third person (indirect handover)

0.26%

Other

9.34%

The Australian Commission on Safety and Quality in Health Care identifies two main evidence-based principles for best practice in handover. Those are face to face communication and documentation, with a combination of both advised3. Evidence suggests that having written information about the patient assists in raising satisfaction with the handover, supporting that both verbal and written handovers are the most useful10,13. Findings showed that regardless of methods, 70% considered their handover adequate to provide safe care.

(NSWNMA survey)

The survey identified that there is no set format for the delivery of nursing handover.

Overwhelmingly, face-to-face verbal, bedside and a combination of verbal and written nursing handovers are experienced by nurses.

A small percentage receive purely written or tape-recorded handover. Qualitative responses showed this was supported by electronic medical records, patient journey boards and written checklists.

Not only is nursing handover a way of transferring professional responsibility, it fulfils other functions including debriefing, exchange of information, education, socialisation and organisation9,11. It can occur at a nurses station, bedside, staffroom or informally during a shift. Handover may not be directly delivered face to face; it may be taped or pre-typed.

There are arguments for and against each of these methods and numerous studies have been undertaken in an attempt to develop a

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definitive solution. However, there remains little doubt that regardless of the method of delivery, safety is a key consideration when establishing the most appropriate method to suit particular healthcare environments.

I think the handover in our Unit is well structured and relevant.

Registered Nurse, Public Hospital

Our handover is set out in ISBAR format, which ensures adequate information is delivered.

Registered Nurse, Public Hospital

Our handover is always relevant, structured and involves others.

Registered Nurse, Community

Our handovers are clear, factual and precise.

Registered Nurse, Residential Aged Care Facility

We have always had a handover

I feel our current handover

sheet/tool and this is most helpful.

system works well.

Registered Nurse, Public Hospital

Registered Nurse, Tresillian Residential Unit

Nurses told us that although the nursing handover is largely attended by registered nurses, midwives and enrolled nurses; AINs and occasionally other members of the wider multidisciplinary team also participate to a lesser extent. Although most nurses felt that the right people attended nursing handover, around 20% considered more staff should be present. Nurses stated that nurse managers, medical staff, AINs and members of the wider multi-disciplinary team, such as physiotherapists would be useful participants. Nurses are required to work holistically and engage other professionals when planning and delivering care. The fact that nurses perceive gaps in attendance is indicative of their awareness of the professional obligations placed on them.

Nurses are well placed to identify who they need to communicate with, but often lack a structured framework to engage with the wider disciplinary team. This leads to gaps in the transfer of information or to information being transferred on an ad-hoc and opportunistic basis.

Findings suggest there are no consistent guidelines to determine which groups of staff attend, despite most healthcare settings being dependent on a multi-disciplinary team to deliver care. The structure of the nursing handover should be reviewed to facilitate better inter-disciplinary communication to enable nurses to practise effectively and provide safer care.

Research has found that nurses are more likely to cover issues related to allied health specialities within the information exchange13. This supports nurses’ recognition of the multidisciplinary nature of care and the value they place on the allied health professional role. Ways in which the nursing handover could be structured to facilitate collaborative multi-disciplinary working is worthy of further research.

On certain days, the presence of allied health would be useful.

Registered Nurse, Public Hospital

Sometimes it would be handy for physios to be present, especially if patients are receiving IPPB therapy or emergency chest physio overnight.

Registered Nurse, Public Hospital

9

Missed opportunities in the nursing handover Only 1% of nurses working in public hospitals and 2% of those working in private hospitals said they didn’t receive a nursing handover.

This figure rose to 8% for those working in residential aged care facilities. This may be because a higher percentage of survey responses from residential aged care facilities were from AINs (40% of total) who are not professionally obliged to participate in nursing handover and do not have the same level of professional responsibility and accountability for the shift.

Of the total number of AIN responses, 90% worked in residential aged care, of whom 14% said they did not receive a handover. This is significant since this staff group delivers the majority of direct care to residents in these settings16. Therefore, they should play a pivotal role in both giving and receiving information about changes to the health status of the people they are caring for.

90

AINs worked in residential % ofaged care and delivered direct care to residents16

Of the total number of AIN responses,

1 in 7

did not receive a handover

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The testimonials of AINs who said they do not receive nursing handover raise serious safety concerns regarding resident care. Errors in the delivery of safe care were highlighted due to a failure to: receive timely updates regarding changes to resident health status; provide information about resident care needs; update them on events that had occurred since their last span of duty. The lack of information also placed workers at risk of exposure to aggressive behaviours and unsafe moving and handling practices. The following testimonials were provided by AINs working in residential aged care who are excluded from nursing handover.

Residents have been given the wrong drink and meals. Instead of puree and thickened, they were given a normal diet.

This caused the resident to choke.

A resident had been re-assessed and now required a wheelchair instead of walking with a frame. This was not handed over and resulted in this person falling when an AIN assisted them to walk.

We were not informed about physically aggressive behaviours from residents or notified of residents who have MRSA. We are told we are on a ‘need to know’ basis and that AINs don’t need to know.

A resident had a stroke and we didn’t know she had gone from one person assist to full two person using an assist sling lift.

The value organisations place on handover impacts on the ability of nurses to fulfil their professional obligations in relation to the transfer of information and responsibility. Almost 30% of community based nurses reported that they do not get a paid handover and 27% did not receive any handover. This was also the largest group who reported not getting an adequate handover in their workplace (32%). Almost 40% of community nurses also said that the structure of the handover was unclear and there was ambiguity around what information should be transferred. Unsurprisingly they reported that, as a consequence, handover was not adequate to maintain safe care.

The findings suggest that those working in residential aged care and community based services are missing vital information about the care needs of the people they are caring for.

Adequate time to complete handover and clear guidelines regarding structure and information to be transferred would assist. Recognition by residential aged care providers and community based services that all staff delivering care require a comprehensive nursing handover is also essential for quality improvement.

Although many of the recommendations of The Garling Report were designed to enhance patient safety in public hospitals, there is relevance for community based services. It is concerning that governance within the public health system in relation to handover has not been extended to nurses delivering community health. Attention should be focused on improving information and transfer of professional responsibility and accountability within NSW community based services.

The client didn’t receive a visit at the time he was available due to it not being passed on that he had something on that day. It meant he missed out on the care required on that visit.

I had a client tell me that she needs a bandage on her leg and when it needs changing. There was no email or progress note informing me of this.

AIN Community (unpaid handover)

Registered Nurse, Community (unpaid handover)

Care needs have been missed.

It is unclear what the priority is for the shift. It is unclear what has been done or not done.

Registered Nurse, Community (no handover)

11

Third-person handover Third-person handover generally involves a nurse who has not been directly involved in the previous span of duty receiving handover from the outgoing nurse, then relaying the information to nurses arriving at a later time or who are unable to participate in the handover directly. This may be supported by written notes and/or taped or video recordings. Only two registered nurses said they receive a third person handover, both working in residential aged care.

However, a third qualitative response suggested this may also occur in community services. This suggests that this is an isolated practice and a strong deviation from normal working practice.

Both nurses working in residential aged care said they would prefer to receive handover from the person directly involved in patient care. Both stated they had received incorrect information about patient care as a result of receiving a third person handover. This is consistent with previous research that found nurses value receiving handover directly from the nurse who has worked with the patient, rather than a person in charge who has not been part of direct care delivery. This increases the accuracy of information as it reduces the amount of times information is transferred11, reducing the possibility of cumulative error occurring in the re-telling and re-interpretation of language and information.

Handover should provide opportunities to cross check information against as many sources of information as possible, preferably whilst the outgoing nurse is still on duty15,17.

Inaccurate details may compromise patient safety by allowing mistakes to be made within subsequent care episodes2,18. The content of information delivered face-to-face is based on the general experience, specific patient knowledge and individual preferences of the information giver19. The personal style of the nurse transferring information means they will emphasise particular facts that may be relevant and influence ongoing care9. It could therefore be argued that using a third person to transfer information would diminish personalisation and lead to failures in prioritisation of care, as well as being subject to further interpretation and translation of information. These factors may reduce reliability.

Handovers were delivered by a third party who passed on incorrect information i.e. that the patient had been made involuntary under the Mental Health Act. They hadn’t checked that information themselves, which meant the involuntary paperwork

Handover should be given by the

was completed incorrectly and

nurse who looked after the patient.

therefore, the patients weren’t

Handover should be received

actually under involuntary status.

by all nurses on the ward, not just the nurses of one team.

Registered Nurse, Public Health

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Registered Nurse, Community

I think the biggest issue for me is that I work afternoon shift and never see the day shift registered nurse (they go home 30 mins before I start).

My handover is via a resident list with notations next to the names.

There are times when professional discussion is imperative. E.g. behaviour changes on one shift do not necessarily mean they are relevant on another shift ... discussion can identify triggers and promote cohesive management.

A very recent incident occurred where a resident had an unwitnessed fall and bruising was noted on her back and arm. The resident is on Warfarin and presented to the afternoon shift 72hrs later with increased confusion / agitation. It would have been nice to have an accurate report on the resident over the previous 8hrs to determine if the change was acute or ongoing ... did she hit her head or did she have a urinary tract infection?

Registered Nurse, Residential Aged Care Facility

Neither of the registered nurses who received third person handover considered that handover had a training function, whereas around 37% of all other nurses did see this as a key purpose. Handover contains an important informal teaching role for junior staff who learn cultural and clinical practices through observations and informal interactions during the handover process3. Having no opportunity to observe such interactions or infrequent noninteractive handovers means training functions are lost9. Therefore, it is of little surprise that members receiving a third person handover consider the training function to be absent. This is a missed opportunity for staff development.

Nursing handover also enhances shared values within the team, promoting cohesiveness, which is essential for quality care20. Nurses are not passive recipients of information; rather the handover is used to question and seek further clarification8. Research suggests that junior nurses use handover to assist them to integrate

within the team22, build team cohesion and communicate values, so it remains a relevant part of nursing practice20. It is an opportunity for discharge planning20,22 and training of junior staff who seek validation for their actions through handover and learn the language of the ward culture. Assurance is given by eye contact between the junior staff and the most senior nurse in the handover20 and this is something that could be lost through purely tape recorded or third person handovers.

Although third person handover appears to be an isolated practice, our results suggest there is potential for errors when using this method, which is consistent with previous findings.

Since registered nurses are required to function within a risk-averse environment, caution should be applied to the implementation of a third person handover until a sound evidence base is established in relation to its ability to ensure safe practice.

13

Bedside handover Over 80% of public hospital nurses, but fewer than 1% of those working in residential aged care perform bedside handover. This was seen as primarily a registered nurse or enrolled nurse function, with only 40% stating it involved AINs. Over 90% said handover at the bedside assisted them to ask questions and clarify information, suggesting it is a highly interactive activity. Over 70% considered it to be the safest way to deliver care. Previous research has shown that patients also value bedside handover and identify key safety outcomes such as being able to correct errors and provide further information23,24,25.

The bedside handover we have enables us to see each patient at the beginning of each shift and the patients/families are encouraged to be involved.

Clinical Nurse Specialist, Palliative Care Unit

Sometimes involving the client leads to general chit chat that’s lovely in that it helps build a bond, but sometimes means I leave late, past sign-off time.

Registered Nurse, Public Hospital

Despite this, 43% of those members undertaking bedside handover in their workplace would like it to be more structured, less rushed and less prone to interruptions. The timing of the handover is also important. Previous research has found that a delay in starting handover resulted in nurses staying behind in their own time following a 12 hour shift, which raises health and safety concerns26. Whilst it is important that handover fits in with the routine of the clinical area, it should also ensure that safe working patterns for staff are maintained and not unnecessarily delay staff from leaving once their span of duty is completed.

A good bed to bed handover is crucial to understanding the care that your patients need. It also allows for communication between staff and patients and staff and staff.

Clinical Nurse Educator, Public Hospital

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<1

%

of those working in residential aged care perform bedside handover

Nurses also raised concerns about maintaining confidentiality during information exchange, particularly in areas where there is more than one patient.

Although confidentiality is widely cited as a potential issue8,11,23,26, this is often discounted due to the perceived benefits of increased patient involvement in the process27. Little research has been undertaken to specifically explore the issue of confidentiality. This will continue to be a concern for many nurses who seek to achieve the balance between meeting professional responsibilities in relation to privacy and confidentiality and the requirement to maintain a partnership approach to the delivery of nursing care.

The structure and content of bedside handover has been found to vary mainly due to concerns about confidentiality, and evidence suggests not all staff agree that patient involvement is beneficial23.

I have issues with privacy in walk around handovers.

A study in a large Australian public hospital found that even within the same hospital there was variance in handover practice and although most were conducted at the bedside, patients were not commonly involved in the handover process28. International research has found that although nurses are able to identify several advantages of bedside handover, most perceive the patients’ role as passive26 and see it primarily as an exchange of information between nurses.

This may be attributable in part to perceived confidentiality issues, but also to workload.

The impact of workload on the bedside handover has been subject to specific analysis in previous research. This found that patients were highly attuned to the workload of nurses and asked less questions or divulged less information when they thought staff were busy. Nurses also tended to involve patients less when their workload was high29. This played a pivotal role in the success of the bedside handover. Although nurses in our study considered that workload did impact on the quality of the bedside handover, 70% said that improving the structure and content would have the largest impact on improving quality.

We are continually taught about privacy and confidentiality and then everything about a patient

When it is busy staff try to rush

is disclosed in a four bed room.

handover so they can get on with their

Clinical Nurse Consultant, Public Hospital

‘work’. This is sometimes frustrating as there are legitimate questions that need to be asked. On the other hand,

Staff should be more involved in

some people waste time by talking

including the patient in handover.

about irrelevant subjects.

There is a reluctance to enter a patient’s room and hand over in the room. Patients want to be involved

Registered Nurse, Public Hospital

and don’t like staff standing outside the room and talking about them.

Registered Nurse, Public Hospital

15

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%

70

at said th ving the impro ture strucontent and c have the would impact on largest ing quality. improv

Providing education and training for nurses would enhance patient involvement and improve the management of the nursing handover11,28. Having structured guidelines for transfer of information heightens nursesâ&#x20AC;&#x2122; confidence. Successful implementation of the bedside handover is dependent on the organisation and the way in which the process is managed27. It is suggested that too much emphasis is placed on implementing rigid protocols, yet there is scope to adapt the format to each clinical area23. Australian research concluded that the bedside handover should not take longer than a traditional nurse to nurse handover and issues such as confidentiality and adapting style to suit the environment could be easily managed8.

There is a good argument for the development of clear competencies in relation

to nursing handover and for further research to establish how nurse education can prepare nurses to provide effective handover30 and clarify the purpose and patientsâ&#x20AC;&#x2122; role23,26.

Educating staff on good communication and the importance of patient involvement in the bedside handover, with practical demonstration of techniques on how to initiate conversation and invite open discussion, would also add value29.

If nurses are to maintain partnerships with patients then it is essential they are supported to deliver safe and efficient bedside handover.

Some work settings have adopted systems such as the wearing of tabards to ensure minimal disturbance and emphasise to members of the wider multi-disciplinary team that the handover is a protected activity. Other methods include separate confidential discussion after the initial walk around so nurses have clear parameters in which to share potentially confidential information. However, for systems such as this to be effective, the employing organisation needs to acknowledge and value bedside handover and ensure governance of the area.

There is scope to establish handover champions in each clinical area to facilitate this.

17

Handover errors

72 nurses

identified that medication errors, omissions or ‘near misses’ had occurred as a result of

poor communication during nursing handover.

72 nurses identified that medication errors, omissions or ‘near misses’ had occurred as a result of poor communication during nursing handover, representing around 6% of the total responses. This is a significant finding and highlights the relevance of nursing handover to safe patient care and risk management.

The same percentage of nurses (6%) identified a correlation between poor care outcomes and inadequate nursing handover.

Handover errors not only impacted on the safety of the people being cared for, but also the safety of staff. A small number of qualitative responses raised concerns about failure to inform oncoming staff of patients/residents/clients who might exhibit challenging behaviours.

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Of interest was that many of the errors occurred in sites that carried out both a written and verbal handover as recommended in the NSW guidelines that were implemented following The Garling Report. Despite the format being consistent with good practice recommendations, many nurses cited lack of time to complete an adequate handover as a contributory factor for errors. This supports that it is not merely the process of informationgiving that is important, but the content of the nursing handover and the environment in which it occurs. The importance of content was recognised by nurses who receive a bedside handover and in research conducted within NSW mental health services, the results of which may provide further information and guidance in relation to safe practice34.

On an occasion (night duty), medications that are scheduled to be given at a certain time were not given/given at a later time and the information wasn’t passed on (so medication was either missed or given at the wrong time).

Not being made aware of injuries sustained by residents, which is essential to know when giving care as you need to accommodate the injury and consider the pain felt by residents when moving the injured limb.

Enrolled Nurse, Public Hospital

AIN, Residential Aged Care Facility

Topical medications applied incorrectly or in the wrong spot.

AIN, Residential Aged Care Facility

Clients had been given medication when they are meant to be fasting. This was due to information missing in the handover.

Registered Nurse, Public Hospital

Falls not being reported in handover.

Constipation not being reported, wound care not being reported resulting in static or infected wounds.

Enrolled Nurse, Residential Aged Care Facility

Finding patients dead; finding patients in a different condition to what was handed over; being handed over the wrong diagnosis; handed over incorrect resuscitation status and directed to give inappropriate care. All as a result of poor handover.

Registered Nurse, Private Hospital

Staff were only able to give handover after a regular medication round. An undocumented nurse-initiated drug was given and was double dosed due to the handover being late.

Registered Nurse – Community

I once accidentally trimmed a resident’s toenails because although I asked the registered nurse about it first, we weren’t aware that the resident was diabetic until after I had done the job. Luckily for all of us, it went smoothly with no injuries.

AIN, Public Health (formerly residential aged care)

19

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Young, aggressive, ‘ETOH’, ‘THC’ and ‘ice’ user with head injury transferred to us at 4pm and had not received any withdrawal therapy or pain relief since 2am as he had ‘maxed out’.

The registered nurse accompanying the patient thought this was acceptable as he hadn’t been aggressive and was sleeping most of day. Of course he became verbally and physically aggressive, threatening staff and patients and security had to be called. The accompanying registered nurse said she hadn’t been told he needed withdrawal meds and hadn’t checked with the ICU nurse allocated to the patient before sending him to us.

Registered Nurse, Public Hospital

Being told an aggressive patient was “settled” then the patient assaulted staff and breached the nurses station on night duty ... 35mins after handovers.

Enrolled Nurse, Forensic Hospital

Bedside handover misses lots of vital information on situations involving violent and aggressive patients and their management and care as it is difficult handing over this information at the bedside.

Registered Nurse, Public Hospital

One time I was expected to care for a female client who needed to be specialled while at the same time had two other clients and an admission. The female client became agitated and when I opened the door I was punched in the jaw and I subsequently suffered a concussion which impacted on my life for some weeks.

Registered Nurse, Public Hospital

21

Unsafe handover â&#x20AC;&#x201C; contributory factors Nurses working in both public hospitals and residential aged care considered that better structured and more relevant handovers would improve safety outcomes. This is consistent with the Australian Commission on Safety and Quality in Health Care guidelines for good practice, which state that the transfer of information about patients should be accurate, unambiguous and timely in order to ensure safe practice3. Since our survey suggests nurses know the key features of safe practice, the reasons this is not always their experience in practice is worthy of further exploration.

Less interruptions would be good.

Registered Nurse, Retirement Village

Consistent with our findings, previous research has shown that nurses are frequently interrupted during handover11. A busy and chaotic environment creates barriers to effective transfer of information22,31, can lead to inconsistent information transfer31 and unnecessary lengthening of the handover process11. Often information is restricted to exception reporting and tasks to be completed rather than discussing opinions or treatment recommendations15. Handover has been found to be particularly disturbed when a shift leader is present22 and it has been recommended that one or two nurses be assigned responsibility for fielding enquires regarding patient care during handover to minimise disruption11.

Just over a quarter (27%) of nurses said there was no set format to their handover and

22 | Do not disturb (NSWNMA survey)

unclear expectations of what information would be dealt with. This view was supported by a previous Australian study, which found more than half of nurses working in a public hospital thought they could have acquired the handover information from written sources. 40% said the information was irrelevant to the patientsâ&#x20AC;&#x2122; care and 35% said handover took too long11.

Is there a set format to your handover with clearly defined expectations of what information will be dealt with?

67.40%

Yes

27.78%

No

Unsure

4.82%

(NSWNMA survey)

A similar study in an acute mental health facility found that despite handover guidelines being implemented, structured handover tools were not used. However, key management decisions were made during handover such as: whether to administer certain medications; discharges and admissions. This emphasises the importance of handover and the need to maintain effective and accurate information throughout.

There is little information regarding nursing handover in acute mental health settings, despite the fact this is a high risk setting17,22. There is heavy reliance on multidisciplinary teams in mental health services and the importance of good communication cannot be overstated22.

Some nurses described the handover process as chaotic with several interruptions, such as people entering and leaving the handover or conversations turning to personal matters. Previous research has found this led to an expectation by staff that less information needed to be shared. Outgoing nurses adapted the expected handover goals to fit the routine of the ward, so content was objectified into medical information about the patientâ&#x20AC;&#x2122;s condition and deviations from the usual course of treatment.

Consequently areas such as patient support, pain management and mobility were omitted15.

Given this evidence, it is clear that regardless of intent, if the environment and organisation in which nurses are working does not value nursing handover or provide a clear

structure, gaps and omissions in care will be heightened. Our survey highlighted areas of concern which were consistent with these previous findings, suggesting that existing research has yet to make the desired impact on the nursing handover. It also highlights the need for evidence-based practice to be implemented across services.

Essential key elements for a good handover also include: sound leadership; shared under­ standing of the purpose of the handover; protected time to complete the handover and a supportive clinical environment32. No system is completely failsafe and our qualitative data suggests there is still much room for improvement in relation to the management of nursing handover.

Some nurses described the handover process as

chaotic

23

Handover can be very complicated and lengthy and take much longer than time allocated.

Handover is done verbally to whole ward then we have to check our paper and computerised charts and notes and sign off on a computer – supposed to take 30 minutes in total but 45 minutes is often required.

Registered Nurse, Public Hospital

We are only allocated 30 minutes for handover; it becomes too complex, discussing issues that are not needed during handover.

Registered Midwife, Public Hospital

Do not send morning staff home early (6 hrs) before the full complement of afternoon staff (incl. the 6 hrs staff) are present so that handover is fully informative.

Registered Nurse, Private Hospital

Have a better spot delegated for us to meet.

We have handover close to the nurses’ desk about 10m away from the whiteboard with all the essential information for handover and it can be distracting when others not part of the handover are standing in front of the board covering the information.

15 minutes is the ‘paid’ time for handover.

It always takes much longer and that should be reflected in the time paid.

Registered Nurse, Public Hospital

30 minutes is allocated for handover from PM shift to night duty but it often needs more time; often things are missed as people want to go home at 10pm.

Enrolled Nurse, Public Hospital (mental health)

Handover sheets have been changed to suit the patient flow portal, this was done with little/ no consultation with the ward staff who have to use them.

Registered Nurse, Public Hospital

Registered Midwife, Public Hospital

Personal attack of one staff to another occurs and staff have used this time as a blame tool – not productive just destructive.

Registered Nurse, Public Hospital

The other members of the multidisciplinary team do not usually start at the same time as the nursing/ midwifery staff.

Clinical Midwife Specialist, Public Hospital

Staff are either leaving when you get there and don’t care about handing over important information or they are already gone before their shift finishes, leaving the floor unattended. There is a lack of communication in the Aged Care facility I work in.

AIN, Residential Aged Care Facility

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A call for governance Members working in residential aged care who did not receive a paid handover was almost

double % 66 that of those in public hospitals

$ Nurses working in private hospitals were the most likely to receive a paid handover, followed by those working in the public health system. The prevalence of members working in residential aged care who did not receive a paid handover was almost double that of those in public hospitals. 66% of those not receiving paid handover attributed this to insufficient time being allocated to complete

attributed this to insufficient time being allocated to complete handover.

handover, despite the fact that, according to 70% of respondents, it normally takes no more than 30 minutes. This suggests they may be routinely staying late or arriving early to facilitate handover, which indicates the length of time allocated within a shift to deliver handover requires review. Handovers may also be unnecessarily prolonged, leading to nurses receiving handover in their own time.

Make handover more efficient and effective. It has to be more streamlined.

Enrolled Nurse, Public Hospital

We do ‘flags’ first by the in charge

A handover tool would be beneficial

nurse. They are usually fairly

if it can be directly linked to be

irrelevant and take up to 45 minutes.

relevant to the patient. Many tools

We are then expected to do a

that have been used in the past are

bedside handover but this is often

not relevant and therefore don’t get

just a repeat of what’s already

completed. EMR is also not utilised

been provided. We often finish late

to its capacity as it requires staff to

because the person giving flags

log on and log off to make entries ...

takes 45 minutes.

surely it can be better.

Registered Nurse, Private Hospital

Registered Nurse, Public Hospital

25

What could be done to improve your handover?

16.53%

Make it shorter

31.53%

Make it more relevant

39.80%

Make it more structured

Involve the person themselves in the handover

Make it longer

12.76%

7.86%

Include other members of the multi-disciplinary team

Include a handover sheet/tool

23.57% 22.55% 24.59%

Other

Greater clarity regarding the patientâ&#x20AC;&#x2122;s management plan is associated with better satisfaction in relation to the handover13.

However, this can only be achieved if sufficient time is allocated to ensure effective information transfer. Since handover is seen as fundamental to safe patient care and a necessary function of nurses during their span of duty, then the expectation should be that this is valued by employers and included as part of contacted hours. This is particularly relevant to aged care settings where it is not uncommon to find higher resident to staff ratios which will naturally lead to extended handover periods.

Allow adequate time.

15 min handover for 121-145 people is not enough.

Registered Nurse, Residential Aged Care Facility

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(NSWNMA survey)

Nurses are pivotal to the delivery of safe 24-hour patient care, which means it is vital that inter-shift communication strategies are optimised2. Hurried and fragmented nursing handover means the training function is lost15.

Practical training delivered through thorough handover practices can assist nurses to develop confidence and competence, particularly in the delivery of bedside handover23. These organisational responses are neither restrictive nor burdensome and should already be embedded within clinical areas, yet our evidence shows that the environment nurses work in continues to create gaps, both in the safe transfer

Allow crossover of shifts so residents arenâ&#x20AC;&#x2122;t left unattended.

AIN, Residential Aged Care Facility

Educate RNs on how to articulate the nursing process.

Registered Nurse, Private Hospital

Carers have not had training

Education of staff in the over use of

in handover and often give or miss

medical terminology, which

relevant information.

they do not understand.

Registered Nurse, Residential Disability Service

Clinical Nurse Specialist, Public Hospital

of information and training of staff in how to deliver and receive information effectively.

considers patient safety may reinforce the transfer of professional responsibility from one shift to another and has been a key focus for safe handover practice in NSW3. However, it is argued that to do this the nurses must feel comfortable that the organisation is supportive of safety concerns being raised. Also that protected time and space is given to the receiving nurse, so they fully comprehend and exchange information regarding plans of care and tasks to be performed4.

Mentoring and leading by example are also identified as necessary to improve nursing handover4. This provides a case for student nurses to participate in handover. The practical experience of both receiving and giving a supervised handover should be a mandatory element of nurse education to ensure new graduates have the skills and competency required to deliver a safe and effective handover, yet student nurses often only attend opportunistically.

Previous research exploring the content of the nursing handover found that a significant amount of information was missed or inadequately discussed14. It is well recognised that ambiguities and incomplete information can increase adverse events and need to be addressed as a matter of urgency2,33.

Shifting the focus of the handover from a purely communicative exercise to one which

Although nursing handover is considered to be a well established part of everyday nursing practice, errors in the giving and receiving of information were identified as far back as 2004 by the British Medical Association. They recognised that these errors were aligned to poor governance and called for a handover champion in each healthcare setting, alongside consistent handover guidelines7. It appears from our survey that this advice remains as relevant to practice today as it did then.

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Conclusion

This survey has added to the body of knowledge around nursing handover and has supported previous research findings. It is concerning that despite numerous evidence-based recommendations advocating for enhanced governance of this area, nurses continue to experience the same shortfalls in relation to the structure, content and organisation of handover. It is clear that a failure to implement clear, consistent leadership of this area continues to affect care outcomes and raise safety concerns for both care recipients and the nursing workforce. Organisations must not lose sight of the recommendations of The Garling Report. Efforts should be re-focused to build on the foundations that it laid in the interests of enhancing patient safety.

28 | Do not disturb

Attempts to remove the nursing handover to reduce costs are counter-productive and devalue the transfer of professional accountability from one span of duty to the next. Rather, employers must seek ways to improve governance of this essential part of the nursesâ&#x20AC;&#x2122; role. Nurses provide a rich source of learnt experience and professional insight and are well placed to provide leadership in this area. However, they must be assured that any advancement of the profession in this regard will be supported by their employer and that the environment in which they work will ensure adequate time and resources. Nursing handover is not a luxury; it is an essential part of professional practice and a key safety measure that must be protected and valued.

References 1. Klemmer, E.T. and Snyder, F.W. (1972) Measurement of Time Spent Communicating in The Journal of Communication, 22. pp. 142-158.

2. Matic, J., Davidson, P.M. and Salamonson, Y. (2010) Review: bringing patient safety to the forefront though structured computerisation during clinical handover, Journal of Clinical Nursing, 20, pp. 184-189.

3. Australian Commission on Safety and Quality in Health Care (2010) The OSSIE Guide to Clinical Handover Improvement. Sydney, NSW: ACSQHC. 4. Lee, S-H. et al (2016) Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture, BMC Health Services Research available at: http://bmchealthservres. biomedcentral.com/articles/10.1186/s12913-016-1502-7 5. Garling, P. (2008) Final Report of the Special Commission Inquiry into Acute Care Services in NSW Public Hospitals. Available at: http://www.dpc.nsw.gov.au/__data/assets/pdf_ file/0003/34194/Overview_-_Special_Commission_Of_Inquiry_Into_Acute_Care_Services_ In_New_South_Wales_Public_Hospitals.pdf 6. NSW Health (2009) Implementation Toolkit: Standard Key Principles for Clinical Handover.

Sydney, NSW Health.

7. British Medical Association (2004) Safe handover: safe patients guidance on clinical handover for clinicians and managers. London: BMA. 8. Chaboyer, W., McMurray,A. and Wallis, M. (2008) Standard operating protocol for implementing bedside handover in nursing. Available at: http://www.safetyandquality.gov.au/wp-content/ uploads/2012/02/SOP-Bedside-Handover.pdf 9. Scovell, S. (2010) Role of the nurse-to-nurse handover in patient care, Nursing Standard, 24(20), pp. 35-39.

10. Pothier, D., Monteiro, P., Mooktiar, M. and Shaw, A. (2005) Pilot study to show the loss of important data in nursing handover, British Journal of Nursing, 14(20), pp. 1090-1093.

11. O’Connell, B., Macdonald, K. and Kelly, C. (2008) Nursing handover. It’s time for change, Contemporary Nurse, 30(1), pp. 2-11.

12. McCloughen, A., O’Brien, L., Gillies, D. and McSherry, C. (2008) Nursing handover within mental health rehabilitation: an exploratory study of practice and perception, International Journal of Mental Health Nursing, 17(4), pp. 487-295.

13. Mukhopadhyay, A. et al (2014) Differences in the handover process and perception between nurses and residents in a critical care setting, Journal of Clinical Nursing, 24, pp. 778-785.

14. Carroll, J.S. et al (2012) The ins and outs of change of shift handoffs between nurses: a communication challenge. British Medical Journal of Quality and Safety, 21(7), pp. 586-593.

15. Drach-Zahavy, A., Goldblatt, H and Maizel, A. (2014) Between standardisation and resilience: nurses’ emergent risk management strategies during handovers, Journal of Clinical Nursing, 24, pp. 592-601.

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16. Australian Government Department of Social Services (2014) 2013-14 Concise Facts & Figures in Aged Care. Available at: https://agedcare.govcms.gov.au/sites/g/files/net1426/f/ documents/11_2014/att_a_-_2013-14_concise_facts_figures_in_aged_care.pdf.

17. Buus, N. (2006) Conventionalized Knowledge: Mental health nurses producing clinical knowledge at intershift handovers, Issues in Mental Health Nursing, 27, pp. 1079-1096.

18. Currie (2002) Improving the efficiency of patient handover, Emergency Nurse, 10(3), pp. 24-27.

19. Engesmo, J. and Tjora, A.H. (2006) Documenting for whom? A symbolic interactionist analysis of technology induced changes of nursing handovers, New Technology, Work and Employment, 21(2), pp. 176-189.

20. Lally, S. (1999) An investigation into the functions of nurses’ communication at the inter-shift handover, Journal of Nursing Management, 7, pp. 29-36.

21. Schwartz, L., Wright, D. and Lavoie-Tremblay, M. (2011) New nurses’ experience of their role within interprofessional health care teams in mental health, Archives of Psychiatric Nursing, 25(3), pp.153-163.

22. Waters, A. et al (2015) Handover of patient information from the crisis assessment and treatment team to the inpatients psychiatric unit, International Journal of Mental Health Nursing, 24, pp. 193-202.

23. Bruton, J. et al (2016) Nurse handover: patient and staff experiences, British Journal of Nursing, 25(7), pp. 386-393.

24. Lu, S., Kerr, D. and McKinlay, L. (2014) Bedside nursing handover: Patients’ opinion, International Journal of Nursing Practice, 20(5), pp. 451-459.

25. Tobiano, G., Chaboyer, W. and McMurray, A. (2012) Family members’ perceptions of the nursing bedside handover, Journal of Clinical Nursing, 22. pp. 192-200.

26. Bruton, J. et al (2016) Nurse handover: patient and staff experiences, British Journal of Nursing, 25(7), pp. 386-393.

27. McMurray, A. et al (2010) Implementing bedside handover: strategies for change management, Journal of Clinical Nursing, 19, pp. 2580-2589.

28. Street, M. et al (2011) Communication at the bedside to enhance patient care: A survey of nurses’ experience and perspective of handover, International Journal of Nursing Practice, 17, pp. 133-140.

29. Drach-Zahavy, A., and Shilman, O. (2014) Patients’ participation during a nursing handover: the role of handover characteristics and patients’ personal traits, Journal of Advanced Nursing, 71(1), pp.136-147.

30. Gordon, M. and Findley, R. (2011) Educational interventions to improve handover in health care: a systematic review, Medical Education in Review, 45, pp. 1081-1089.

31. Bost, N. et al (2012) Clinical handover of patients arriving by ambulance to a hospital emergency department: A qualitative study, International Emergency Nursing, 20(3), pp. 133 – 141.

32. Jorm, C.M., White, S. and Kaneen, T. (2009) Clinical handover: critical communications.

Medical Journal of Australia, 190(11), pp. 108-109.

33. Thomas, M.L. (2012) Failures in transition: learning from incidents relating to clinical handover in acute care, Journal for Healthcare Quality, 35(3) pp. 49-56.

34. Cowan, D & Luo, C (2016). Handover innovations project Northern Sydney and Mid North Coast LHDs. 30 | Do not disturb

Do not disturb Findings from the NSWNMA nursing handover survey

NSW Nurses and Midwives’ Association Australian Nursing and Midwifery Federation NSW Branch 50 O’Dea Avenue Waterloo NSW 2017 phone

8595 1234 (metro) 1300 367 962 (non-metro)

www.nswnma.asn.au

NSWNMA/ANMF NSW Branch Legal Disclaimer This publication contains information, advice and guidance to help members of the NSWNMA/ ANMF NSW Branch. It is intended to use within New South Wales but readers are advised that practices may vary in each country and outside New South Wales.

The information in this booklet has been compiled from professional sources, but it’s accuracy is not guaranteed. While every effort has been made to ensure that the NSWNMA/ ANMF NSW Branch provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used. Accordingly, the NSWNMA/ ANMF NSW Branch shall not be liable to any person or entity with repect to any loss or damage caused or alleged to be caused directly or indirectly by what is contained in or left out of this information and guidance.

Publised by the NSWNMA/ ANMF NSW Branch, 50 O’Dea Avenue, Waterloo NSW 2017, Australia. © 2016 NSWNMA/ ANMF NSW Branch. All rights reserved. Other than as permitted by law no part of this publication may be produced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publisher. This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is publised, without the prior consent of the Publisher.

ISBN 978-0-646-90471-9 (Australia) Issued December 2016.

Authorised by Brett Holmes, General Secretary, NSWNMA and Branch Secretary, ANMF NSW Branch, September 2016

NSW Nurses and Midwives’ Association

Professional issues | 3

NSW Nurses and Midwivesâ&#x20AC;&#x2122; Association

Professional issues | 3

Do not disturb Findings from the NSWNMA nursing handover survey

ISBN 978-0-646-90471-9 I Issued December 2016