7Resource: communicating effectively in bedside nursing handovers
Suzanne Eggins and Diana Slade
7.1Introduction
Chapter 6 described the challenges nurses faced at the research site when implementing the mandated policy of bedside handovers. In response to our research findings, and with the strong support of the local health department, we developed a two-hour training module ‘Better Bedside Handovers’, and a train-the-trainer package. At time of writing we have delivered this training to more than 300 nurses and nurse-managers. The training is described in full in Slade et al. (in preparation). In this chapter we summarize the training module design and present the communication protocols and tools that we developed.
7.2Training design
We designed the training intervention to cycle through four components:
- Creating engagement: We reviewed the risks of poor handover, the role of communication in handover and the safety and quality benefits of handing over at the bedside. We also elicited nurses’ reservations about bedside handover compared to other handover modes such as staff room handovers (e.g. privacy and confidentiality issues, duration, etc). This brief introductory stage had two aims: (a) to encourage participants to commit to the new practice because of its demonstrated safety and quality advantages; (b) to acknowledge that nurses need to develop new strategies to manage the real contextual constraints of handing over at the bedside.
- Self-reflection: Training groups watched and discussed professionally re-enacted videos of actual bedside handovers recorded on site, identifying more and less effective practice. Through discussion we supported participants to recognize that (a) handovers are most effective when nurses involve the patient and the handover team in the handover; (b) handovers are most effective when clinicians share information that is accurate, concise and organized in a logical sequence.
- Input in the form of practical communication protocols and strategies – we present these resources below.
- Role play activities based on actual patient cases and ward scenarios to practice and reinforce the new communication skills.
- Workshop wrap-up: Here we re-visited the participants’ reservations about bedside handover, suggesting that the new communication strategies they had acquired during the workshop showed how many of the challenges could be managed collaboratively with patients and ward management.
In the next sections we include the material we gave nurses as part of the input phase of the training. As reported in Slade et al. (under review) we evaluated the training through questionnaires immediately after the session, and at a three-month interval. In the post-training questionnaire, over 96% of the 200 nurses we trained found the training very useful and 97% strongly recommended it for all other nurses in their wards. For the train-the-trainer sessions with senior nurse–managers, over 90% found the training very useful and strongly recommended it for other senior nurses. To compare pre-and post-training handovers, we audio and video recorded bedside handovers and interviews with nursing staff three months after the training. These pre- and post-trainingvideos were analyzed by independent raters. As detailed in Slade et al. (in preparation), the results showed statistically significant differences, demonstratingthat the training had resulted in improvements to the content and manner of the clinical handovers consistent with the input and activities outlined below.
7.2.1Dimensions of a good bedside handover
As described in chapter 6, we drew on the distinction between interactional and informational dimensions of handover. We framed the subsequent communication protocols by presenting the summary in Tab. 7.1.
We then presented two communication protocols: CARE to help nurses with the interactional dimension and an adaptation of iSBAR for the informational dimension.
Tab. 7.1: Summary of dimensions of effective bedside handover
| To achieve a safe and effective bedside handover, the whole handover team needs to manage two dimensions well: |
| 1. Interactional dimensions: how you talk |
| Outgoing nurse: You need to include the patient and your colleagues in the handover. |
| Incoming nurses: You need to establish a relationship with the patient and participate actively in the handover. |
| 2. Informational dimensions: what you say |
| Outgoing nurse: You need to handover clearly and concisely relevant clinical information that accurately portrays the patient and that prepares your colleagues for their shift. |
| Incoming nurses: You need to make sure you know and understand everything you believe you need to about the patient. |
| Interactive handovers are good for people and for information |
| Outgoing nurse: if you interact more, you’re likely to get better information from the patient and better continuity of care from your colleagues. |
| Patients: if nurses include the patient, the patient is likely to be better informed, more satisfied and compliant. |
| Incoming nurses: if you interact more, you’re more likely to retain information from the handover and know what you have to do on your shift. |
7.2.2Interactional dimensions of bedside handover: the CARE communication protocol
Table 7.2 summarizes the CARE protocol that we encourage nurses to follow. Table 7.3 provides language examples of each stage in the protocol.
7.2.3Informational dimensions
To support nurses in the informational dimension of bedside handover, we used the iSBAR protocol as hospital B strongly encouraged all nursing, medical and allied health staff to use it in their handovers. As explained in chapter 1, the iSBAR protocol aims to help clinicians collate the minimum dataset of information they need to handover and to present their handover in an orderly sequence. However, uptake of iSBAR among nurses was very low, partly due to lack of training in its use and partly because the standard definition of the iSBAR elements is oriented to doctors who have the authority to assess the patient and recommend a treatment plan. As linguists, we also noted that the tool implied a monologic view of handover, although as pointed out in chapter 1, handover is by definition an interactive (dialogic) event.
The mandated status of the tool and its widespread use across Australia encouraged us to try to adapt it for the nursing handover context. In this we were influenced by Porteous et al.’s (2009) adaptation of iSBAR in the West Australian context, described in detail in chapter 9. We therefore applied the principle of ‘flexible standardization’ from the Australian clinical handover standard (ACSQHC 2012b). We re-glossed the iSBAR elements in nursing-oriented terms and stressed that these iSBAR elements constituted the minimum dataset nurses should pass to their colleagues at hand over. In doing this we drew on Porteous et al.’s revisions although we have not adopted all of them. We also brought out the underlying past–present– future temporal structure implied by iSBAR. We encouraged nurses to try to structure their verbal handover so that they moved in an orderly fashion from the past, through the present and on to the future. We encouraged them to avoid jumping around between past, present and future information by following the iSBAR structure in sequence. Finally, we linked iSBAR to CARE, repeatedly emphasizing and demonstrating through examples that an effective handover involves both interactive and the informational dimensions. Table 7.4 shows our re-glossing of the iSBAR components.
Tab. 7.2: The CARE protocol for bedside nursing handover
| CARE | |
| Connect | Greet the patient; introduce yourself and the team. At the end, thank the patient and say goodbye. |
| Ask | Find out what the patient knows. Find out what your colleagues know. Encourage interaction. |
| Respond | Listen and react to whatever the patient and your colleagues say. |
| Empathize | Respect sensitivities and be aware of the patient’s feelings. |
Tab. 7.3: Language examples demonstrating the CARE protocol
| CARE in brief | ||
| Connect | Greet the patient; | 1. N1: Hi. How are you? |
| introduce yourself | John: Howdy! | |
| and the team; at | N2: We’re the night staff. | |
| the end thank the | N1: ==Oh, no we’re not | |
| patient and say | John: ==Hallo, night staff! | |
| goodbye | N1: We’re not, we’re not. We’re the evening staff. | |
| 2. June, I’m just going to hand over to the afternoon staff, OK? | ||
| June: Yes, thank you Helen | ||
| 3. Jim, I’m just here with the afternoon shift nurses. This is Luisa who’ll be looking after you this afternoon. I need to brief everyone about how to care for you so please feel free to contribute. | ||
| Ask | Find out what the patient knows; find out what your colleagues know | 1. N: Has that new medication helped you? Have the doctors been to see you this morning? Has the doctor been back to see you? |
| 2. N: You’re feeling better today, aren’t you? You had a difficult night, didn’t you? | ||
| Respond | Listen and react to whatever the patient and your colleagues say | N: What did you get the cellulitis from? A bite |
| John: I had salmonella | ||
| N: I see. You’ve been to the Miramar Bakery? | ||
| All: [laughter] | ||
| John: I have, yes. You’re very observant, Sue. ==So that was a couple of weeks ago. | ||
| N: I wondered how long – I wondered how long before we got the ==overflow from that | ||
| John: Yeah, I was pretty crook for a bit …. | ||
| N: Indeed | ||
| Empathize | Respect sensitivities and be aware of the patient’s feelings | 1. P: ... due to the MS I have to stretch a bit and you know |
| N: Sure, to ease the discomfort. | ||
| 2. P: Panadeine forte. Has that got codeine in it? | ||
| N: Yes. Oh, sorry, you’re allergic to codeine, | ||
| aren’t you? | ||
| 3. N: You’re absolutely right, I don’t blame you. You tried all the right things | ||
| 4. N: No, you’re not going crazy. I can appreciate how uncomfortable it must feel. It’s not a very nice test. |
Tab. 7.4: The iSBAR communication protocol adapted for nursing handovers
7.2.4Use of transcribed examples from actual handovers
Our training is always based on and supported by de-identified actual examples collected during our onsite research. As well as the re-enacted video clips that we show participants, we also provide sample texts which we play-read and discuss. Chapter 6 presents several transcripts that foreground issues in the interactional dimension of handover. Table 7.3 above exemplifies the CARE components.
For informational dimensions and their interaction with interpersonal dimensions, Tab. 7.5 below, ‘Janet’, shows the outgoing nurse building up her recommendations throughout the handover and then providing a readback or summary before concluding. This nurse also demonstrates CARE strategies by involving the patient. The nurse first connects with the patient and later directly asks and responds to patient input and displays empathy by checking how the patient feels.
The example in Tab. 7.6, ‘Henry’, can be used to demonstrate less effective informational and interactional strategies. Information structure is poor: the outgoing nurse mixes background and situational information (and so jumps around between the past and the present). The nurse also fails to present clear recommendations – she does not clearly state what needs to be done in the future. The handover is also weak on the interactional side, with no use of CARE strategies to involve the patient – the patient is talked about but not to. As we make clear in chapter 6 and in Eggins & Slade (2016) we believe that poor interactional performance contributes to poor informational outcomes.
7.2.5Information structure on ward sheets
We also use de-identified examples of ward sheets from different wards. This stimulates discussion of how iSBAR can be used to collate, summarize and structure the written information about patients that nurses have access to during the handover. In our training we stress the role of the verbal handover to add value to available written information – not merely to repeat it – while covering all the necessary elements in an orderly sequence. For example, Tab. 7.7 shows an iSBAR-structured ward sheet. This, or similar locally adapted examples, can be used as follows:
- Nurses can discuss the quality of the information on the ward sheet: Which entries are clear or confusing, adequate or too brief etc? Are all the columns useful? Are any relevant categories of information missing?
- Nurses can discuss how they could implement iSBAR into their ward sheets or other documents in their wards, e.g. when writing up patient notes at the end of their shift.
- Nurses can discuss the relationship between the verbal handover and written supports like the ward sheets. In our training we emphasize that the verbal handover should add value to available written information while covering all the necessary elements in an orderly sequence.
Tab. 7.5: ‘Janet’ transcript showing iSBAR and CARE elements
4. Nurses can use the entries in the ward sheet as the basis for practice role plays: participants can be asked to act out handovers for the patients on the ward sheet, applying CARE and iSBAR communication strategies. In performing their role plays nurses should demonstrate the ability to extend on, correct, update or explain the most pertinent aspects of a patient’s case. They should not merely verbalize written information already recorded on the ward sheet.
Tab. 7.6: ‘Henry’ transcript showing problems with iSBAR and CARE components
7.3Conclusion: changing practice through targeted training
As mentioned earlier, we evaluated the bedside handover training qualitatively and quantitatively. Slade et al. (in preparation) details our quantitative evaluation methodology and findings. Qualitatively, analysis of the pre- and post-training videos three months after training showed that nurses who had attended training had significantly modified their handover practices:
–Nurses were giving handovers at the patients’ bedside, not in the corridor.
–Nurses no longer stood with their backs to patients.
–Outgoing nurses explicitly introduced the patient to the team and to the incoming nurse who would be responsible for their care.
–The incoming nurse greeted the patient.
–Outgoing nurses asked the patient at the end if s/ he wanted to add anything to the handover (and most patients did).
–Patient contributions were not cut off or ignored.
–There were frequent moments of shared humor. The atmosphere during handover had become friendly and open.
–Nurses checked information with patients during the handover, eliciting collaborative accounts with patients.
Among the incoming team, we also observed a marked increase in interactions with the patient and with other team members. Receiving nurses were actively engaged in the handover. They asked the outgoing nurse clarification questions, sometimes even querying information.
Tab. 7.7: Use of iSBAR to summarize and structure written information about patients on a sample ward sheet
These findings brought home to us the need for communication training to support changes in handover modalities. The nurses at hospital B never intended to be insensitive to the needs of the patients. As soon as they watched re-enacted videos of poor bedside handovers, they recognized the impact of such handover styles on patients. They realized that handing over at the bedside called for different communication behaviors than handing over in the staff room. Our brief but highly targeted training module gave them the confidence and skills to hand over professionally, efficiently and inclusively at the bedside.