Clinical handover has long been an important topic among both clinicians and academics interested and involved in patient safety in healthcare. It is widely recognised that clinical handover represents a vital, yet vulnerable, link in the chain, ensuring continuity of care for all patients during their hospital stay (Ong and Coiera, 2011; Scott et al, 2012; ten Cate and Young, 2012; Moore, 2012).
Extensive knowledge has also been imported from other high-risk industries, such as aviation, nuclear power and the armed forces, and adapted for use within healthcare settings (Gaba, 2000; Singh, 2009; Kapur et al, 2016). However, to date, very little is known about what can be considered to be best evidence-based practice in clinical handover on labour ward (Spranzi, 2014). Childbirth is a unique event in life. In the UK, childbirth is expected to have a positive outcome, both for mother and infant. Overall, the provision of maternity care in the UK is considered of an excellent standard. Current figures for England and Wales show neonatal mortality rate at 2.7 per 1 000 live births (Office for National Statistics, 2018). Some of these deaths may be unavoidable; however, some may be preventable.
Evidence suggests that as many as 1 in 10 patients admitted to hospital may be at risk of harm as a result of receiving medical care (Vincent et al, 2001; de Vries et al, 2008; World Health Organization, 2014). Safety and quality are considered key concepts within the provision of all kind of services in modern society. Patient safety and quality improvement have become major issues in healthcare in the past decade. The publication in the US 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 quality and patient-safety awareness 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.
Furthermore, over half of clinical errors are considered preventable (Hogan et al, 2012). It is clear that preventing unnecessary deaths and morbidity related to receiving medical care remains one of the biggest and most challenging issues in modern healthcare systems worldwide (Adhikari, 2013; Shojania and Thomas, 2013). Maternity care is not immune to this intrinsic threat to its patients. However, the provision of maternity care is unique. Its uniqueness rests on many factors, including:
Within patient safety, communication breakdown is widely considered to be a significant factor contributing to poor patient outcomes with handover being a major risk point (Rabøl et al, 2011; Foster and Manser, 2012; Kapadia and Addison, 2012). The majority of these communication failures are considered preventable. Communication is particularly pertinent within maternity care. In the UK, poor communication within maternity and obstetric services has been consistently identified in all recent ‘Confidential Enquiries into Maternal Deaths’ reports (Lewis and Drife, 2004; Lewis 2007; 2011; Knight et al, 2018) and the King's Fund report (O'Neill, 2008) as a contributing factor to poor maternal and fetal outcome.
The publication of the ‘Report of the Morecambe Bay Investigation’ (Kirkup, 2015) further confirms this. The report states that at the Furness General Hospital (part of the Morecambe Bay NHS Foundation Trust) between 1 January 2004 to 30 June 2013, 11 babies and one mother died unnecessarily because of clinical errors in their care. These deaths could have been prevented and should not have happened. During the investigation, problems in communication during handover were identified as contributing factors to poor care that led to these deaths. A combination of the increasing complexity of care – requiring a multidisciplinary team approach – and the growing number of shift changes for healthcare staff makes handover of care a critical point in patient care (Manjunath and Srirangam, 2010).
An in-depth literature review on clinical handover on labour ward was the first step of this service evaluation and has been published elsewhere (Spranzi, 2014). In contrast to the abundance of literature available on handover in clinical areas other than maternity (Cohen and Hilligoss, 2010; Manser and Foster, 2011; Raduma-Tomas et al, 2011; Scott et al, 2012; Segall et al, 2012; Symons et al, 2012), the literature available on clinical handover on labour ward is limited and heterogeneous. Nine studies in total were included and analysed thematically. The themes identified in the literature review revealed that the discussion on handover on labour ward appears to resonate with the broader discussion about handover in other clinical settings, in particular with regard to the use of mnemonics, including situation, background, assessment, recommendation (SBAR), a communication tool widely recommended throughout the NHS.
In line with the wider research on handover in other clinical settings, one theme emerged from the literature review on clinical handover on labour ward: a structured and standardised approach to handover, mainly through the use of mnemonics (Riesenberg, 2009) improves communication (Spranzi, 2014). Although the use of mnemonics in healthcare is now the focus of a growing debate, it is nonetheless recognised that a structured approach to clinical communication continues to represent a pivotal element in clinical communication (Patterson, 2008; Siassakos et al, 2011; Russ et al, 2013; Rydenfält et al, 2013; Haider et al, 2014; Hilligoss and Moffatt-Bruce, 2014). This article reports on the findings of a service evaluation. The aim was to explore the current practice of clinical handover on labour ward.
Methods
The service evaluation was structured in four stages, each using a different design and research method. The first stage was a review of the internal hospital ‘Handover of Care: Maternity Guideline’ (2011) in use at the time of the study. This guideline was used as a reference point to assess handover practice and related documentation within the maternity unit where the work took place.
The second stage had a dual purpose: to map the patient journey from admission through labour ward to transfer to postnatal ward, as well as to assess compliance with the internal guideline in terms of handover documentation. This was a retrospective cohort audit collecting quantitative data using a study specific proforma to record data. A convenience sample of 60 medical records of women admitted to labour ward between October 2013 to March 2014, regardless of their risk status on admission, who delivered a live term infant (37–42 weeks gestation) were audited. Length of stay on labour ward, number and type of handovers were noted and handover documentation compliance against the internal guideline were reviewed.
The third stage consisted of a prospective audit of clinical handover as it currently occurred on labour ward using a study-specific observational proforma. In light of the commonly accepted definition below (British Medical Association [BMA], 2004), three different types of handover were identified on labour ward:
A convenience sample of 40 handovers in total was used. Observations took place on labour ward between October 2013 and March 2014.
The fourth stage aimed to assess the perceived importance, risks and effectiveness of clinical handover on labour ward among patients and staff, using patient and staff study specific questionnaires and interviews. A convenience sample of potential participants was identified. Participants were approached on hospital premises during working hours and selected on a voluntary basis. No monetary or other reward was offered. Detailed written information regarding the project was given to potential participants as well as time for deciding whether to participate or not. Interviews were carried out on hospital premises and lasted up to 30 minutes. Interpreters were not provided. Questionnaires were completed by the participants before the interview took place. Interviews were digitally recorded, professionally transcribed verbatim and analysed thematically.
For the purpose of this work the following definition of clinical handover was 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).
Service evaluation setting
The work was undertaken between September 2013 to August 2014 in a maternity unit in a large NHS teaching hospital in London, UK. The unit provides a full range of maternity/obstetric services, from midwifery led care to complex high-risk care for a population with a varied social and ethnic background. In total, there are approximately 3 500 births a year in the unit.
The labour ward of this unit consists of 10 delivery rooms (two with a birthing pool), a four-bed high dependency area and two operating theatres, all on the same floor. Staff present on labour ward include: midwives, obstetricians, anaesthetists, neonatologists (if and when required), healthcare assistants, ward administrators and managers, and ancillary staff for catering and cleaning.
Results
Review of internal hospital guideline
In January 2011, the NHS hospital where the project took place issued a guideline on handover in maternity based on SBAR.
Two key elements of the guideline were found on review:
Compliance with this guideline was assessed in stages two and three of this work.
Retrospective cohort audit
In total, 556 handover entries (n=292 midwives; n=264 doctors) were reviewed for content and structure (Table 1). Two main findings emerged from the retrospective audit. Firstly, there was virtually no compliance with the local guideline in terms of handover documentation. Of the 556 handover entries audited in patients' notes, only two were documented using the SBAR structure. In the majority of cases, the handover documentation in the medical notes is limited to ‘care handed over to…’ Secondly, the median length of stay (14 hours) and the median number of handovers for each patient (10) confirm that handover is a highly repetitive and frequent clinical activity on labour ward. This is because it is not unusual for women in labour to stay on the ward for many hours, therefore receiving care from various members of staff across different shifts.
| Variable | Category | Median (range) or N (%) |
|---|---|---|
| Transfer to postnatal form | Complete | 16 (27%) |
| Incomplete | 21 (35%) | |
| No | 23 (38%) | |
| Mnemonic used during handover | No | 58 (97%) |
| Once | 2 (3%) | |
| More than once | 0 (0%) | |
| Number of midwife handovers | - | 4 (1, 18) |
| Number of midwife handovers (categorical) | 1−2 | 11 (18%) |
| 3−5 | 30 (50%) | |
| 6−10 | 81 (30%) | |
| 11+ | 1 (2%) | |
| Number of doctor handovers | - | 3 (0, 21) |
| Number of doctor handovers (categorical) | 0 | 9 (15%) |
| 1−2 | 17 (28%) | |
| 3−5 | 18 (30%) | |
| 6−10 | 11 (18%) | |
| 11+ | 5 (8%) | |
| Number of midwife handovers in labour ward stay | - | 1 (0, 5) |
| Number of midwife handovers in labour ward stay (categorical) | 0 | 9 (15%) |
| 1 | 34 (57%) | |
| 2 | 13 (22%) | |
| 3+ | 4 (7%) | |
| Number of office handovers in labour ward stay | - | 1 (0, 6) |
| Number of office handovers in labour ward stay (categorical) | 0 | 8 (13%) |
| 1 | 33 (55%) | |
| 2 | 14 (23%) | |
| 3+ | 5 (8%) | |
| Total number of handovers | - | 10 (2, 50) |
| Total number of handovers (categorical) | 1−5 | 14 (23%) |
| 6−10 | 19 (32%) | |
| 11−15 | 10 (17%) | |
| 16−20 | 12 (20%) | |
| > 20 | 5 (8%) | |
| Time on labour ward (hours) | - | 14 (3, 68) |
| Time on labour ward (categorical) | ≤ 6 hrs | 11 (18%) |
| 6−12 hrs | 18 (30%) | |
| 12−18 hrs | 17 (28%) | |
| 18−24 hrs | 8 (13%) | |
| > 24 hrs | 6 (10%) |
Prospective observations
A total of 40 direct observations were completed: midwives' handover in the office (n=10); doctors' handover in the office (n=5); midwife-to-midwife handover (n=15); midwife-to-doctor handover (n=10). As in the retrospective medical notes review audit, all observations highlighted the discrepancy between the hospital guideline and actual clinical practice, with nearly non-existent compliance.
No SBAR structure was used in any of the handovers observed. Instead, a chronological order was followed when discussing each individual patient present on the ward. The past obstetric and medical history tended to be discussed first, followed by a detailed description of the current clinical situation. Plan of care – other than immediate clinical actions needed – was rarely discussed during handover. During one-to-one, midwife-to-midwife handover, all the midwives observed supplemented verbal handover by taking notes on volatile media, mainly loose pieces of paper that are then discarded in the confidential bin at the end of the shift (Figure 2 and Figure 3). Yet, midwives reported during the interviews that they refer to these pieces of information throughout their shift.
One midwife reported during the interview:
‘Yes, I usually use this piece of paper when I hand over the care again to someone else as well if I need to hand over at some point for an emergency or something. I usually look at that piece of paper.’ —Participant 4
This written supplementation of clinical information appears to be a peculiarity of one-to-one midwife handovers. It was not observed happening during office or doctors' handovers.
Questionnaires and interviews
In total, 27 questionnaires and 27 interviews were completed. Year three student midwives (n=3); staff junior midwives (n=9); senior midwives (n=5); a junior obstetric doctor (n=1); senior obstetric doctors (n=2); obstetric consultants (n=2); patients (women who gave birth in the unit to a live infant within five days prior to the interviews) (n=5).
Emerging themes during the interviews were consistent with direct observations of handover in clinical practice.
Staff
Staff interviewed reported being confused regarding the recommended use of SBAR during routine handover. They reported not having received formal training. One year three student midwife said:
‘No, not that I can remember. I don't think we've had any kind of formal training on it. We've been told about SBAR. But never, we've never had any specific training on how to do a handover.’ -Participant 20
A junior midwife said:
‘Some mentors would talk you through how they do it, but sometimes you just learnt by looking or watching or making mistakes. And then them butting in. I wouldn't say I was formally trained in how to give a handover at all.’ -Participant 5
Another midwife who has been working at the hospital over four years reported:
‘No, I haven't received any particular training. I read on posters about SBAR but no one told me to do it. Or I haven't been trained to do it.’ -Participant 4
Staff – as well as patients – appeared to be aware of the importance of accurate handover and, conversely, to be aware of the risks associated to missing, incomplete or inaccurate information during handover. One year three student midwife reported the following:
‘I think, definitely think, that I can see that happening. I can really see a very slight error, and it's not even, it's almost not even an error at the time that it's done. It's not, it's just maybe a bit of misinformation or a slight misunderstanding in communication or something like that. And it's just handed over and it almost gets worse, a bit like Chinese whispers, it's like it's never a big – you know, you're not just not completely misunderstood right at the beginning, it's just slight misunderstandings or slight errors that then build up to something. I can definitely see that happening very easily.’ -Participant 20
Midwives also reported they preferred using a chronological order – rather than SBAR – for information transfer, matching the structure of the handheld paper maternity notes, which are used as guidance. One year three student midwife reported the following advice given to her by a consultant during handover:
‘I learnt through observing other midwives and doctors doing a handover, and I was actually told by, the one that stuck with me especially was when I was in first year and I was speaking to a consultant, and I was always getting really confused about where to start in the notes. And he said, “It's very simple, you just start at the beginning and work your way through the woman's notes,” and after that yes, it makes a lot more sense, that I just start from the beginning and work my way forward to the present day really.’ -Participant 21
One junior midwife said:
‘And basically we just follow the notes. So I mean, and demographic details, risk factors, past medical and general history, and then the actual pregnancy. I think it's more or less for everyone.’ -Participant 6
One senior midwife also reported:
‘I follow the medical notes. So usually I say their rhesus status of the woman and her rubella status, if the virology is negative or positive. Then I go through the medical history, then I go through the allergies. Then the parity, any problems with those previous pregnancies. Then I go and talk about the actual pregnancy and then where we are at the moment. And yes, the plan of care possibly.’ -Participant 14
This approach to information transfer during handover confirms the results which emerged during the direct observations of handover, where midwives have been observed ‘flipping through’ the medical notes in sequential order during handover.
Patients
Patients appeared to be aware of handover happening frequently. One patient reported:
‘Yes, it happens a lot, you see a lot of different midwives in the short time you are here, not really informed of what's going on.’ -Participant 23
Patients also appeared aware of handover being an important and critical point in their care. One patient reported:
‘And because I had been here for a couple of weeks before, I already have a preconceived notion that handover was, is dangerous, it scared me that I was in the middle of, I was at the height of my distress, they were changing shift. And they were changing shift without really understanding, it's just that where we were in the diagnosis process, no one really understood what was happening, you know, was I going to have a massive haemorrhage? Was there..? What was the problem, what was going on? The same patient adds: “I think there's definitely room for improvement.” I had a situation exactly of that nature that was very stressful … And then finally at 4.30 in the morning I went out and asked. It was like they said, “Well, the registrar said if you refuse to have the blood test, then, you know, it's kind of your decision. It was just so frustrating, you know. I am not refusing the blood test. I mean it's in my self-interest to do this. But, you know, why can't you tell me what the four or five vials that we've collected over the last 48 hours were?” So I'm sure that was handover, you know, missing it.’ -Participant 27
On the positive side, when handover happens smoothly, patients appreciate and feel ‘safe’:
‘For my stay, it was excellent. I felt really comfortable. There was no points I didn't know who to shout to for help or to answer questions or, you know, I just felt quite secure knowing that I was being looked after.’ -Participant 24
Discussion
Clinical handover on labour ward is a complex activity. It is a fairly consistent process as described in the literature (Hunt, 1995; Sen and Paterson-Brown, 2005; Amirchetty and Rutheford, 2008; Wright and Kean, 2011) although there might be minor local variations.
This service evaluation has brought to light various discrepancies between what appears to be the best evidence to guide clinical practice – as recommended in the literature and included in clinical guidelines – and the actual handover practice on labour ward. This dissonance is clear and marked, and raises a few questions.
‘Handover’ is a general term. The accepted and still widely used definition (BMA, 2004) is clear yet very broad, therefore leaving it open to different interpretations and translations into clinical practice. It is a definition that acts as an umbrella under which different clinical activities take place. Different professional groups – such as midwives and obstetricians – have different priorities and different modus operandi. A ‘one size fits all’ approach is unlikely to provide an effective way forward. The wish for standardisation should therefore not become a goal in itself: different clinical needs for each professional group should be acknowledged and careful consideration given to effective and constructive multidisciplinary team working rather than a blank and superimposed standardisation (Bruton et al, 2016; National Institute for Health and Care Excellence, 2018).
It appears that maybe the time has come to consider a new alternative conceptual model of communication during handover. Moving from handover to takeover – meaning that the incoming member of staff, who is rested and fresh, is leading the information transfer – may enhance the quality of information transfer itself. Fatigue and lack of concentration are not unusual at the end of a long shift and they are known to have a direct impact on the accuracy of the handover process. Furthermore, the incoming member of staff is from the point of handover onwards professionally and legally responsible and accountable for the care provided. It is, therefore, important that this change in responsibility and accountability is reflected in the handover process in clinical practice.
‘From handover to takeover’ is therefore a new and innovative approach to handover, not currently found in the literature. Historically, research on handover has concentrated on the quantity and quality of the information transferred, moving gradually towards assessing the impact on information transfer of other quantifiable factors, such as the medium used (eg verbal versus written) or the environment (eg number of disruptions, like telephone calls), and exploring the behaviour of the person receiving handover.
The proposed takeover model takes a further step to reflect the shift in emphasis and leadership from outgoing to incoming members of staff. Changing from ‘handover’ to ‘takeover’, meaning that the incoming member of staff, who is rested and fresh, is leading the information transfer during handover by asking structured questions to the outgoing member of staff finishing the shift. In this way, the quality of handover cannot be impaired by the fatigue or lack of concentration of the outgoing member of staff. The main reason for this is that the main handover happens at the end of a 12-hour shift, often as a culmination of a very busy, and both physically and mentally demanding, shift. By switching the leading role from the outgoing to the incoming staff, a reduction in miscommunication incidents due to fatigue and lack of concentration is anticipated. It is expected that the incoming midwife will be fully alert, bringing a fresh-eyed approach when assessing the clinical needs of the labouring woman.
The results of this service evaluation also suggest that SBAR may not be the most appropriate mnemonic for change of shift handover, in particular for the one-to-one, midwife-to-midwife handover. The main reason for this is that SBAR was initially devised to be used in emergency situations (Leonard et al, 2004). However, the purpose and practicalities of change of shift handover bring to light different needs. Change of shift handover is not an emergency situation, but rather a routine practice aimed to ensure continuity of care for patients during their hospital stay.
Two studies included in the preliminary literature review for this project (Spranzi, 2014) reported the introduction of a new mnemonic alternative to SBAR during handover, with a concomitant reduction in clinical incidents, even if, as the authors clearly stress, no direct causation nor correlation could be established (Ottewill et al, 2007; Hatten-Masterson et al, 2009).
The results of this service evaluation encourage a tentative suggestion for a new mnemonic alternative to SBAR: 5Ps (patient, past, present, plan, pending).
The 5Ps mnemonic in detail:
The new 5Ps mnemonic reflects more closely the true meaning of routine change of shift handover: ‘telling a story’ about a patient, therefore following a chronological order.
Verba volant, scripta manent, an old Latin proverb says, meaning ‘spoken words fly away, written words remain’. Documentation is a key element of any aspect of care provision within the health system. This also applies to handover on labour ward. It is interesting to note that the lack of clear and structured documentation in the medical notes seems to be counter-balanced by the abundance of clinical handover information documented on volatile media, such as loose paper, paper hand towels, old receipts and train tickets. All this information never reaches the medical notes: instead, it is discarded in the confidential bin at the end of the shift. Yet, midwives refer to these pieces of information throughout their shift, as if this ghost information plays a hidden but pivotal role in maternity care provision. A paradox that may require further consideration.
The majority of midwives – as directly observed and as reported during the interview – write patient information during handover: this is indicative that verbal only handover may not be the most appropriate method. It is recognised that the act itself of physically writing a piece of information reinforces information retention (Bhabra, 2007). However, more work is needed to identify the most effective handover method. The Cochrane Systematic Review conducted in 2014 (Smeulers et al, 2014) failed to identify eligible studies that compared different styles of nursing handover, suggesting further research in this area is urgently needed. Lastly, it is also often said ‘what is not documented, never happened’: the legal implications of clinical documentation should not be underestimated.
Conclusion
This service evaluation has presented a limited yet focused evidence surrounding the practice of handover of care on labour ward within the wider context of patient safety and quality of care. ‘Meant is not said’, ‘said is not heard’, ‘heard is not understood’ and ‘understood is not done’ (Brindley and Reynolds, 2011): patient information flow should be efficient but, crucially, all patient information needs to be acted upon. Handover is clearly a key element in this process. However, it appears that there is still plenty of space for improvement.
The results of this service evaluation open the horizon to a Galilean change of perspective on handover, with a shift in emphasis and leadership from the outgoing to the incoming members of staff who will lead the information transfer by asking structured questions. This new approach will ensure that fatigue and lack of concentration will not have a negative impact on the accuracy and relevance of the information transfer. The ultimate aim is to support staff and protect patients against potential harm due to clinical errors set in motion by incomplete or inaccurate information transfer during handover. Within this new conceptual model of handover, a different mnemonic alternative to SBAR is also suggested.
Furthermore, this new approach could be applied across clinical areas other than maternity. The ‘takeover’ model has the potential to transform in-hospital clinical communication during change of shift handover, with great benefit for patients (safety) and staff (satisfaction). The high frequency of clinical handover means that even a small improvement could result in a big impact on clinical care provided.