Clinical handover has long been identified as a critical point in patient care. Safety and quality are considered key concepts within the provision of services in modern society. The publication in the USA in 2000 of the report To Err is Human: Building a Safer Health System (Kohn et al, 2000) is still regarded as a milestone for raising awareness of quality and patient safety within healthcare. It brought to public attention the paradox that every year millions of patients worldwide suffer adverse outcomes as a result of receiving medical care. Among clinical errors, communication breakdown is widely considered to be a significant contributing factor to poor patient outcomes, with handover being a major risk point. Communication is particularly pertinent within maternity care. In the UK, poor communication within maternity services has been consistently identified in all recent Confidential Enquiries into Maternal Deaths reports (Lewis and Drife, 2004; Lewis, 2007; Cantwell et al, 2011) and the King's Fund report (O'Neill, 2008), as a contributing factor to poor maternal and fetal outcome.
In 2010, Pezzolesi and colleagues undertook a retrospective review (cohort analysis) of data retrieved from the clinical incidents database of a medium-sized UK hospital over a period of 3 years. A total of 334 handover incidents were identified, with the majority (41.9%) occurring in the ‘obstetrics and gynaecology department’, followed by ‘medicine for the elderly’ (12.2%). The authors speculate that this may be due to the fact that mother and baby are counted as one patient when in fact they should be counted separately (Pezzolesi et al, 2010). However, even halving the figure, obstetrics and gynaecology still represents the leading specialty for clinical incidents related to handover of care. It is therefore imperative that clinical handover on the labour ward undergoes increased scrutiny, research and development.
Extensive literature is available on handover in clinical settings other than in labour wards, particularly in perioperative clinical areas (Manser et al, 2013), accident and emergency departments (Talbot and Bleetman, 2007) and intensive therapy units (Cohen and Hilligoss, 2010; Raduma-Tomas et al, 2011; Segall et al, 2012). Numerous literature reviews on the subject are also available (Manser and Foster, 2011; Foster and Manser, 2012; Scott et al, 2012;Abraham et al, 2013), including a Cochrane review on nursing handover styles (Smeulers et al, 2014) which identified 2178 citations, and analysed 28 but found no studies eligible for inclusion in the review, as no randomised controlled trials were retrieved. The authors conclude that more rigorous and well-structured studies were needed to assess which handover style provides the best handover method. In contrast to the abundance of literature available on clinical handover in general terms, little is available on handover of care on the labour ward. Based on the current search no systematic review has been undertaken on this topic.
This literature review focuses specifically and exclusively on clinical handover on the labour ward with the aim of identifying both existing knowledge and current gaps in the evidence. It is hoped that the findings of this literature review will provide a clear direction for further research in this field.
Definitions
The labour ward is the clinical area that provides 24/7 care to women during childbirth and in the immediate postnatal period. Although pregnancy and childbirth are physiological events, the labour ward itself is often considered to be a high-risk clinical area. This is because childbirth can be unpredictable and the fetal or maternal condition can deteriorate rapidly. If not acted on quickly and appropriately, it may result in poor outcomes to both mother and baby.
Many definitions of handover are available in the literature (British Medical Association (BMA), 2004; World Health Organization, 2007; Jeffcott et al, 2009). For the purpose of this literature review the following definition is used: ‘handover is the transfer of information, professional responsibility and accountability for some or all aspects of care for a patient, or a group of patients, to another person or professional group on a temporary or permanent basis’ (BMA, 2004: 7).
Handover of care on the labour ward occurs at various points during a 24 hour period, mainly for change of shift between day and night staff and for temporary substitution of staff during meal breaks. As for other clinical areas, best practice suggests having multidisciplinary handovers. On the labour ward this should include: midwives, obstetricians, anaesthetists and healthcare assistants. However, there is anecdotal evidence that handovers often occur separately for midwives and for medical staff, with the labour ward coordinator being the link between the two professional groups.
Methods
Data sources and search strategy
Following an initial search of the Cochrane Library, clinical studies were identified via OvidSP Medline(R) (1946 to week 3 November 2013), OvidSP CINHAL (1981 to week 3 November 2013) and OvidSP Maternity and Infant Care (1971 to week 3 November 2013).
A facet analysis was carried out and both general free text and MeSH (medical subject headings) terms were been used to maximise retrieval. Wild cards were used according to each database. Further hand searching of retrieved articles reference lists located additional relevant articles. Boolean operators OR and AND were used to construct a specific search strategy equation. Results from all searches were combined and duplicates removed and are represented using a PRISMA flow chart (Moher et al, 2009) (Figure 1).
Inclusion criteria
All empirical research studies and opinion articles focusing on clinical handover on the labour ward, regardless of research method or study design.
Exclusion criteria
All studies and articles not meeting the inclusion criteria. Given the small number of studies retrieved, no specific limit—such as time or English language only—were applied.
Results
A total of 26 studies and articles were identified as eligible for full text analysis. Thirteen were subsequently excluded as they did not specifically focus on handover on labour wards, although they mentioned handover in the wider context of multiprofessional communication and team working on labour wards. In total, nine studies were included and analysed thematically in this review (Table 1). Three further articles and one book chapter were excluded but are listed separately as they provide a detailed description of the practicalities of handover on labour wards (Table 2).
| Author/s | Year | Title | Theme | Research methods | Results |
|---|---|---|---|---|---|
| Ottewill et al | 2007 | Safe hand-over: safe care | Mnemonics | Initial steering group to discuss an alternative mnemonic to SBAR. Introduction of the new mnemonic followed by focus groups (n=4) and questionnaires (n=139) | A standardised approach to handover, using the CHAPS mnemonic specifically adapted to maternity, improves the quality of handover |
| Hatten-Masterson and Griffiths | 2009 | SHARED maternity care: enhancing clinical communication in a private maternity hospital setting | Mnemonics | Pre- and post-study design using clinician surveys, chart audits, patient satisfaction surveys and a review of clinical incident data to measure change in satisfaction, attitudes and practice with handover and documentation | A standardised approach to handover, using the SHARED framework with a standardised minimum dataset, improves the accuracy and appropriateness of information |
| Chin et al | 2011 | Patients' perceptions of safety and quality of maternity clinical handover | Patient perception | Semi-structured postnatal patient interviews (n=30) plus audit of related medical records | Patients are aware of handover process but express mixed views regarding their direct involvement in handover. Importance to include patients' birth plan in handover |
| Chin et al | 2012 | Transferring responsibility and accountability in maternity care: clinicians defining their boundaries of practice in relation to clinical handover | Staff perception | A qualitative study of semi-structured interviews (n=27 face-to-face and 6 written) and focus groups (n= 18) of maternity clinicians | Lack of consensus among maternity clinicians about the transition of responsibility and accountability during handover |
| Edozien | 2011 | Structured Multidisciplinary Intershift Handover (SMITH): a tool for promoting safer intrapartum care | Mnemonics | Opinion paper reporting on a structured multidisciplinary inter-shift handover (SMITH) which encompasses pre-handover, handover and post-handover behaviour | Need for a structured multidisciplinary handover (including pre- and post-handover activities). Handover should be regarded not as an end but as the beginning of the process of maintaining individual and team situational awareness throughout the shift |
| Toeima | 2011 | SHARING - improving and documentation of handover: Mind the gap | Mnemonics | Opinion paper describing SHARING as a systematic method of transferring information and responsibility during handover | Need for a structured written handover tool, the SHARING document is more of an organisational pro-forma to ensure that all patients of concern are included in the handover at the end of each shift. It also suggests that junior doctors should be trained and prepared for handover while still at medical school and prior to qualification |
| Basu et al | 2011 | Onsite handover of clinical care: implementing modified CHAPS | Mnemonics | Retrospective audit of medical records covering a period of 6 weeks | Poor documentation is identified as the main weakness during handover |
| Poot et al | 2013 | Exploring perinatal shift-to-shift handover communication and process: an observational study | Mnemonics | Structured direct observations of shift-to-shift patient handovers (n=70) in an academic perinatal setting. Afterwards, receivers' opinions of handover communication (n=51) were measured using a questionnaire | High variability in handover process plus inadequate staff awareness of potential risks associated to poor handover |
| Block et al | 2013 | Measuring handoff quality in labor and delivery: development, validation and application of the Coordination of Handoff Effectiveness Questionnaire (CHEQ) | Psychometric quality tool | A prospective, non-blinded intervention study to (1) evaluate the psychometric properties of a new questionnaire, the coordination of handoff effectiveness questionnaire (CHEQ) for measuring the quality of handoff interactions on labour ward and (2) to demonstrate the utility of the CHEQ in evaluating the effectiveness of a previously described intervention, the ‘tangible handoff’, for standardising handover on labour ward. The CHEQ was administered to 56 eligible labour ward clinicians pre- and post-implementation of the ‘tangible handoff’ intervention | The CHEQ is psychometrically sound for evaluating handover quality and may be replicated or adapted for other clinical areas to investigate handover and inform the design and evaluation of handover interventions |
| Author/s | Year | Title | Results |
|---|---|---|---|
| Hunt and Symonds | 1995 | The Social Meaning of Midwifery (chapter 7, pages 113-137) | First comprehensive description of clinical handover on labour ward, giving some vivid verbatim transcriptions of actual handover communications. It is interesting to note that very little seems to have changed when comparing this description - now dating back nearly 20 years - to more recent accounts of handover on labour ward, as if the passage of years had no impact on this highly repetitive yet vital clinical task |
| Sen and Paterson-Brown | 2005 | Prioritisation on the delivery suite | All three articles describe handover as a clinical tool to prioritise patients on labour ward according to their clinical needs. Written by different authors and published three years apart, these three descriptions are similar in approach and content. One minor yet noteworthy detail is the fact that the discussion on handover within each article happens progressively earlier in each article, suggesting that clinical handover has increased in importance as the years pass. |
| Amirchetty and Rutheford | 2008 | Prioritisation on the delivery suite | |
| Wright and Kean | 2011 | Prioritisation on the delivery suite |
Included studies and articles
Nine studies were included and analysed thematically in this review (Table 1). Six discuss the use of mnemonics in the context of clinical handover on labour wards. The details of the mnemonics used during handover on labour wards are listed in Table 3.
| Author/s | Year | Mnemonic | |
|---|---|---|---|
| Ottewill et al | 2007 | CHAPS | Clinical picture |
| History | |||
| Assessment | |||
| Plan | |||
| Sharing information | |||
| Hatten-Masterson and Griffiths | 2009 | SHARED | Situation |
| History | |||
| Assessment | |||
| Risk | |||
| Expectation | |||
| Documentation | |||
| Basu et al | 2011 | CHAPS (modified) | Clinical picture |
| History | |||
| Assessment | |||
| Plan | |||
| Signature | |||
| Toeima | 2011 | SHARING | Staff |
| High risk | |||
| Awaiting theatre | |||
| Referrals | |||
| Inductions | |||
| NICU (open/closed) | |||
| Gynaecology ward | |||
| Edozien | 2011 | SMITH | Structured |
| Multidisciplinary | |||
| InTershift | |||
| Handover | |||
| Poot et al | 2013 | SBAR | Situation |
| Background | |||
| Assessment | |||
| Recommendation | |||
Edozien (2011) and Toeima (2011) describe the principles, benefits and content of a structured handover tool to be used during handover. Ottewill et al (2007) and Hatten-Masterson and Griffiths (2009) report on the development, introduction and evaluation of a new mnemonic, with a particular focus on midwives. Both studies also describe the supporting material used during the intervention, such as posters, credit-card size reminders, and stickers. Both acknowledge the importance of these artefacts in contributing to the success of the project. In 2011, Basu and colleagues adapted the mnemonic developed by Ottewill et al (2007), but focus on ‘doctor to doctor’ handover rather than on midwives. The observational study by Poot and colleagues (2013) highlights the discrepancy between the data observed (suboptimal use of the recommended SBAR mnemonic during handover on labour wards) and staff perception (very positive opinion of the quality of handover). The authors suggest that the lack of awareness among staff that patient safety is threatened during handover should be addressed before an intervention is put in place.
Of the remaining three studies, one reports on the challenges in validation of a new tool to assess the quality of handover on labour wards through a questionnaire for staff (Block et al, 2013), the second investigates clinical handover perception among staff (Chin et al, 2012) while the third explores patient perception on handover, including patient views on their involvement in handover during labour (Chin et al, 2011).
Patient involvement in healthcare is a growing theme in the broader discussion of patient safety. The reason behind this approach is the increasing evidence that patients can act as error buffers. Handover is gradually moving from the office or the corridor to the bedside and staff are encouraged to involve patients by asking direct questions (Griffin, 2010).
Chin et al (2011) suggest a widespread awareness of clinical handover among patients. However, this study also shows mixed views expressed by the postnatal women interviewed. Women in the study see the direct involvement in handover during labour positively as it represents the opportunity to take an active role in their own care. However, when health professionals asked questions directly to women during handover, it was interpreted by some as a sign of lack of efficient communication between health professionals. This can potentially lead to an erosion of confidence and trust, compromising the delicate relationship between woman and health professional, with potential detrimental effects on the overall safety and quality of care provided.
Discussion
Overall, the literature available on clinical handover on labour wards is limited; therefore it has not been possible to undertake a meta-analysis. Instead, the results are presented as a narrative synthesis. The literature retrieved seems to suggest that the debate surrounding clinical handover on labour wards is, relatively speaking, in its infancy.
The key theme that stands out is the use of mnemonics during handover on labour wards. Alongside standardisation and formal structure of clinical handover, the use of mnemonics has long been identified as an important step to improve inter- and intra-professional communication (BMA, 2004; The Joint Commission, 2006; Royal College of Obstetricians and Gynaecologists, 2010). Riesenberg et al reported the use of 24 different mnemonics across different clinical settings in their systematic review of handover (Riesenberg et al, 2009).
One of the most popular mnemonic used in the NHS is SBAR (situation, background, assessment, recommendation). It was originally conceived for use in US nuclear submarine communication (Leonard et al, 2004; Haig et al, 2006), but has been successfully transferred worldwide into clinical settings. In 2008, the then NHS Institute for Innovation and Improvement issued a specific guidance on how to use SBAR as a quality and service improvement tool (NHS Institute for Innovation and Improvement, 2008). However, only one study focusing on the use of SBAR in maternity was retrieved (Poot et al, 2013), suggesting that either SBAR is rarely used in maternity settings, or that it is used but finds no resonance in the literature.
It is interesting to note that two intervention studies reporting on the introduction of a new mnemonic for handover on labour wards (Ottewill et al, 2007; Hatten-Masterson and Griffiths, 2009) also report a post-intervention reduction of clinical incidents. However, both state that neither clear correlation nor causation can be established.
Only four studies report on a specific intervention aimed to improve clinical handover on labour wards (Ottewill et al, 2007; Hatten-Masterson and Griffiths, 2009; Basu et al, 2011; Block et al, 2013), while the majority of the studies included in this literature review are theoretical/descriptive studies or observational. This larger group tends to include handover as part of a broader discussion on labour ward management or multiprofessional communication and team working.
The finding that a larger proportion of studies are observational and theoretical/descriptive is unsurprising, as an in-depth knowledge of a topic is required in order to conceive and implement targeted interventions. It is not uncommon for a large number of theoretical/descriptive and observational studies to be published before intervention research projects become more widespread. When appropriate, the maturity and saturation of a research field is usually marked by the appearance of cost-effectiveness studies on the topic. No cost-effectiveness studies on clinical handover on the labour ward have been retrieved, suggesting that this topic has not yet reached its peak in terms of research interest.
Clinical handover of care on the labour ward is a complex yet vital activity to ensure continuity of care for patients. The themes identified in this literature review reveal that the discussion surrounding handover on the labour ward appears to echo the wider and more comprehensive debate about handover in other clinical settings, in particular with regard to the use of mnemonics and patient involvement. However, although lessons can be learned from other clinical areas, it is important to stress that the provision of maternity care is unique, requiring a specific adaptation of existing knowledge or new targeted research. Furthermore, a recent systematic review on interventions aimed to improve clinical handover across clinical settings (Robertson et al, 2014) highlights the lack of consistent and reliable methodology in study design, implying that, to date, there is not clear and sufficient evidence to guide clinical practice.
Limitations
There are two main limitations to this literature review. First, the inclusion criteria for full text analysis and critical appraisal are very broad. This was an intentional decision. The decision to keep the criteria wide was dictated by the limited number of studies identified during an initial explorative search on clinical handover on the labour ward. It was therefore decided that this approach would result in a sensitive yet not very specific literature review, fulfilling its scope to assess the extent of the current knowledge on clinical handover on the labour ward and to provide a clear direction for further research in this field
Second, this literature review was carried out by a single author, contrary to the common practice to have multiple independent reviewers looking at the literature. Again, this follows the results of the initial explorative search. Should the literature available have been more substantial, permitting a systematic review, a second or even a third reviewer would have been involved. For the purpose of this literature review a single author was deemed sufficient.
Recommendations for clinical practice
Based on the limitations and findings of this literature review on handover of care on the labour ward there is insufficient evidence to make any specific recommendation for clinical practice.
Conclusion
Despite the overall growing interest in clinical handover and the strong evidence that poor handover is linked to poor patient outcome, there is still limited research focusing on clinical handover on the labour ward. This in itself could be considered as being a significant limitation since it may weaken any conclusion derived from the discussion presented in this literature review. However, from a different and more positive perspective, this paucity and heterogeneity, combined with the consolidated knowledge on the importance of handover in the provision of safe and high quality care, should instead be interpreted as a strong indicator that further research on this topic is urgently needed. Many questions remain unanswered or require clarification. It is in the interest of women in labour to clarify which intervention is likely to have a clear and measurable impact on her safety and quality of care provided on the labour ward.