15iCARE3: an integrated translational model of effective clinical handover communication
Suzanne Eggins, Fiona Geddes and Diana Slade
15.1Setting the scene
Our final example of a handover event brings together many of the challenges with clinical handover identified in earlier chapters.
Early one weekday evening, Sartaj12, a tall, strong man who speaks English as a second language, brought his wife Indira to hospital B’s emergency department. Indira was 33-weeks pregnant and had suffered a miscarriage in the past. The couple were of Indian background. Sartaj told the triage nurse that Indira was complaining of nausea and vomiting and had headaches. Sartaj explained that he had taken Indira to the other major public hospital in the city earlier in the day, but that she had been discharged home after a few hours in their emergency department.
Several hours later, hospital B’s emergency department night registrar examined Indira. He found her unwell – still nauseous and complaining of severe headaches. He was unable to reach a diagnosis but wanted to admit Indira for observation and tests. However, no beds were available in the antenatal ward. He made several phone calls to consultants and other wards, looking for a bed where Indira could be cared for while she waited for a bed in antenatal. At around 3 am Indira was admitted to Ward M, the hospital’s general medical ward, where she stayed for 10 hours before being transferred to a bed in the antenatal ward.
Throughout her admission and handover, Indira was accompanied by Sartaj. With the consent of Sartaj and Indira, an ECCHo researcher observed and audiorecorded the transfer from Ward M to the antenatal ward.
Subsequent analysis of the transcript and review of the case revealed 12 risk factors in Indira’s hospital journey to the point of her arrival at the antenatal ward. Communication was directly implicated in at least 10 of these factors:
- Night time admission to the emergency department: International statistics show that night time admission is more dangerous than daytime admission. In Indira’s case, there were fewer and less experienced staff at the time of her arrival at the emergency department and subsequent transfer to a ward, than during the day. Consultants were available only by phone. The night registrar was not able to negotiate a bed for Indira in the antenatal ward, and no obstetric, infectious diseases or neurological consultants were present to review Indira.
- Transfer from the emergency department to a holding ward, Ward M: When reviewing this case later with the researcher, the Ward M nursing manager said: ‘This patient should never have come to us’. Ward M had no staff with appropriate antenatal qualifications or experience. Had the admission happened during the day, when the nursing manager would have been on duty, she said she would have ‘strongly argued’ that this patient should go directly to antenatal.
- Clinical handover of patient among general medical nurses: Because Indira was still in Ward M at 7 am, she was handed over to an incoming Ward M nurse – let us call him Bernardo. This constituted a handover from one non-antenatal nurse to a second non-antenatal nurse. Subsequent events indicated that Bernardo did not fully understand the information given to him at 7am. None of the more senior nurses present at the 7 am handover checked Bernardo’s understanding or offered advice.
- Inexperience, poor language competence and anxiety of the Ward M nurse handing over to antenatal: After taking over Indira’s care, Bernardo – who spoke very poor English – had trouble making himself understood by other clinicians and the family. As a new graduate he had limited skills and experience. Bernardo was highly anxious throughout his care of Indira, both in Ward M and during the Ward M to antenatal ward transfer, for which he was solely responsible. He kept saying to Sartaj, the patient’s husband: ‘I’m doing my best but I not antenatal nurse – I just a new grad.’
- Miscommunication in written information from the emergency department: The admitting doctor’s name on the patient’s file was incorrect. Bernardo spent several hours paging the wrong doctor and got no response. This problem was only resolved when Bernardo asked a doctor who happened to be in Ward M to help him with the patient. This doctor then realized who the patient was really assigned to and paged the right doctor on Bernardo’s behalf. The correct doctor told Bernardo he hadn’t known the patient was in Ward M.
- Incomplete and illegible patient notes: Bernardo had been told at morning handover that a midwife had visited the patient during the night. But there was no information in the patient’s record about this visit or its outcome. The overnight notes were also illegible – Bernardo could not read information he was supposed to hand over.
- Lack of preparation in the receiving ward: When Bernardo, Indira and Sartaj arrived at the antenatal ward, the nurses there did not seem to know which room Indira was to go in. This was despite a call having been made to Ward M saying that an antenatal bed was ready for her. One nurse told the orderly to wheel Indira’s bed into one spot. Minutes later another nurse came by and said Indira had to be moved to a different room. Meanwhile, Sartaj and Bernardo were left standing in the corridor. At this point no-one had claimed responsibility for taking over Indira’s care on behalf of the antenatal team.
- Failure to include the family member in the handover: No staff in the incoming ward interacted with the patient’s husband at any time, despite the fact that he was clearly very anxious and – it later emerged – already known to the antenatal staff from his wife’s previous admission after a miscarriage. In conversation with the ECCHo researcher after the handover, one staff member in the antenatal ward described the husband as ‘aggressive’. However, to the researcher he seemed concerned and legitimately frustrated by the way his wife’s case was being managed. Indira had already been discharged from another local hospital when she was clearly unwell. There was confusion about the admitting doctor. There were delays in getting her to the correct ward. There was confusion and delay in the antenatal ward. The interpersonal failure to interact with Sartaj created an informational failure, as indicated in the next risk factor.
- Relevant information not communicated to the patient and carer/family member: Sartaj had been given no information about his wife’s possible diagnosis or treatment plan. In fact, throughout the observed transfer, no clinical staff took the time or had the knowledge to explain to Indira or Sartaj what was happening. As Text 15.1 below shows, when Sartaj and Bernardo are told to wait in the corridor they become united in their mutual lack of information and together read Indira’s partially illegible medical notes to try to work out what is happening.
Text 15.1 Corridor discussion
10.Delay in taking the handover: It was not until around 10 minutes after Indira’s arrival in the new ward that the nurse taking the handover, let’s call her Pamela, noticed Bernardo waiting in the corridor and identified herself. Before the handover could be given, the antenatal nurses had helped the patient to pass urine in the toilet – no-one had asked Bernardo whether or not this was appropriate. At handover, Pamela learned that this patient was on a strict fluid balance chart and must use the pan. Indira had not been told this.
11.Poor physical environment for the handover: A six-minute handover eventually took place at the nurses’ station. Another conversation was going on there, making it difficult for Bernardo and Pamela to hear one another. Midway through the handover a person wandered up to the nurses’ station and interrupted, asking for directions. Then the phone rang and was answered by another nurse, producing an overlapping conversation. A minute later the phone rang again. Even though she was receiving Indira’s handover, Pamela answered the phone. It was her daughter calling.
12.Divided attention of receiving nurse: Throughout the handover Pamela had to field inquiries and answer the phone even though she was concurrently receiving the handover for a very sick patient. When Pamela’s daughter called, Pamela said to her daughter, ‘I’ll be two ticks’. She then put the phone down on the desk and continued to take the handover, clearly keen to finish it quickly. The daughter would have been able to hear everything that was going on at the nurses’ station – a breach of patient confidentiality as well as an indication that the nurse’s attention was not fully focused on the handover.
15.2Accumulating problems as systemic risks in clinical handover
Indira’s case was a routine event that occurs many times daily in hospitals around Australia and internationally, yet it displayed a disconcerting list of risk factors. In Indira’s case nothing catastrophic happened. Fortunately, she received good care in the antenatal ward from the daytime staff, with multiple teams reviewing and managing her case, and so potential risk was averted. She was discharged home two days later.
However, Indira’s case brings together and underscores three significant points about clinical handover communication that emerged across the ECCHo research sites. First, while a patient’s safety is rarely jeopardized by a single catastrophic ‘mistake’ by a single clinician or team, far more commonly patients are exposed to an accumulation of multiple problems that can potentially put patient safety at risk.
Second, given the local nature of patient care, it is rare for any one person to see these problems stacking up; no-one is therefore in a position to recognize the potentially serious implications for patient safety. Clinicians involved in a patient’s care see only the interactions and events that they are involved in – not the entire process of care as it unfolds in real time.
Third, while many of these accumulating problems seem at first glance to be apparently ‘minor’, and the ‘fault’ of specific individuals involved with a specific patient in a specific context, this not the case. Most of the common problems are in fact systemic, recurring in different combinations with different patients and different clinical staff, day after day. They recur because the structure, values and procedures of hospitals allow – and perhaps even provoke – such problems.
Take Indira’s case. The accumulation of problems goes unseen by anyone except the accidental researcher. Some of the problems in the chain appear relatively ‘simple’ issues, easily fixed if identified and acted on promptly by the individuals concerned. For example, couldn’t Bernardo have insisted on giving the handover as soon as he arrived with the patient in the antenatal ward? Couldn’t the nurse taking the handover simply have said to a colleague ‘I’m taking handover. Please staff the desk while I go into the staff room’? Couldn’t that same nurse have invited Indira’s husband into the staff room to be part of the handover?
However, on closer inspection it becomes apparent that the source of the problems is far deeper than individual behavioral choices on a particular day in a particular context. Bernardo could not insist on giving the handover as soon as he arrived in the antenatal ward because he was simultaneously struggling with English as a second language and care of a patient that went well beyond his junior competencies and scope of practice. The nurse receiving the handover could not delegate manning the nurses’ station because no other staff were available — all the nurses were on the ward caring for patients. And the nurse receiving the handover could not invite the patient’s husband to be part of the handover because including carers in handover was not a value she saw reflected in the day-to-day practices of the hospital, nor did she have the training to manage such an inclusive handover.
In pooling research results from around Australia, the ECCHo team came to acknowledge that most of the problems we were identifying in clinical handovers are most accurately viewed as systemic in origin. They arise from underlying institutional systems and organizational contexts that militate against the conduct of effective and safe clinical handovers. We see these problems in Indira’s case and in the many other handover examples discussed in this book. We know from the ECCHo survey, interviews and informal discussions that clinicians and managers recognize that these risky practices go on. But tolerance for these problems has become naturalized as a routine part of the fabric of hospital health care. ‘Yeah, it’s not great,’ clinicians have said to us, ‘but that’s how it’s done round here. There’s nothing I can do about it.’
These systemic problems reflect a high institutional tolerance for risky practices, based on the implicit assumption that in most cases the problems will not cumulatively lead to an adverse event for the patient. And indeed, much of the time this is true. As discussed in chapter 8, the redundancy and repetition in hospital care can provide a protective factor. If the 7 am handover is incomplete, the 1 pm handover may be more comprehensive. If the night registrar’s notes are illegible, perhaps the daytime registrar’s will be decipherable.
However, the assumption that later events will compensate for earlier inadequacies represents a gamble. As James Reason’s (1997) ‘Swiss cheese’ model of human error captures so powerfully, when errors in different parts of the system overlap, catastrophic outcomes become a real possibility. Statistics on iatrogenic harm underscore the seriousness of the problem, with Landrigan et al.’s (2010: 2573) study suggesting that ‘harm remain[s] common, with little evidence of widespread improvement’.
Being able to analyze contributing factors – adverse or benign – after the event offers useful but limited insights. The goal of the ECCHo research has always been to translate the analysis of actual handover data into effective ways of predicting and avoiding risks in communication in clinical handover. While individual chapters of this book have offered resources to improve communication in specific handover contexts, in this chapter we draw together the insights and outcomes of the research across all four sites to offer an integrated model of effective communication in clinical handover. Given our analysis of Indira’s case, as a first step in presenting our model we apply James Reason’s human factors systems approach to risk to acknowledge the contributing layers and actors in risks to patient safety.
15.3Interpreting risk: applying a systems approach to clinical handover
The human factors systems approach to managing error developed from analyses of the relatively rare incidence of catastrophes in high risk industries such as nuclear power and aviation (Lucas 1997; Rasmussen 1990; Reason 1990, 1997, 2000). Applying the systems model to health care means that rather than laying the blame for errors in handover practice at the feet of the individual – still the dominant approach in responding to medical error – research identifies weaknesses in the system. As James Reason explains:
The basic premise in the system approach is that humans are fallible and errors are to be expected, even in the best organizations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in ‘upstream’ systemic factors. (Reason 2000: 768)
A systems model allows us to recognize the role of both active failures (‘unsafe acts committed by people who are in direct contact with the patient or system’) and latent factors (inherent underlying problems within the system, what Reason refers to as ‘resident pathogens’). The model also captures the important distinction between unintentional errors (where individuals simply make a mistake) and violations (where individuals actively subvert official protocols, policies or practices). Violations may indicate personal decisions to ignore rules and policies but they may also highlight organizational requirements that employees do not consider ‘workable’ or necessary.
Fig. 15.1: The Swiss cheese model applied to clinical handover events (adapted from Reason 1997)
Applying this model of human error to Indira’s nursing handover, we can classify the sequence of problems we observed as either active or latent conditions:
–active failures:
–unintentional errors: incorrect admitting doctor’s name in medical records (5); receiving ward not ready, despite having agreed to be so (7); divided attention of the receiving nurse (12)
–violations: failure to ensure written records are legible and complete (6); failure to include the family member in the handover (8); failure to communicate relevant information to patient and family member (9); delay in taking the handover (10);
–latent conditions: night time admission to the emergency department (1); poor physical environment for the handover (11), no bed available in specialist ward (2) requiring medical nurse to manage a situation outside his ‘scope of practice’ (3) and requiring medical nurse to manage a situation beyond his competencies (4).
15.4Identifying types of communication risks in clinical handover
Although the systems approach broadly recognizes communication as a risk factor, specifying the exact role of communication has been hampered by a lack of sophisticated close-up language analysis of empirical interactional data by systems theorists. However, the findings of the ECCHo research allow us to identify communicative dimensions of risk, which can then be interpreted within the categories of active failures and latent factors.
Figure 15.2 captures the three dimensions of risk in which communication is implicated: contextual, interactional and informational risks. These three dimensions emerged from the ECCHo team’s analyses of national data, as reported in the chapters of this book.
To better capture how these communicative dimensions are implicated in systemic risk, in Tab. 15.1 we develop a typology of communication risks in clinical handover. Again, we draw directly on examples of communication problems from the ECCHo corpus presented in this book, cross-categorized as active errors or latent failures.
15.4.1Latent factors and active errors in clinical handover
In Tab. 15.1 we depict the complex relationship between the underlying latent factors in healthcare systems and the active errors we observed in communication during clinical handovers from all the research sites. Active errors arose because staff were not well trained in more effective or inclusive ways of handing over, or because they were obliged to hand over in environments that undermined effective communication.
Violations often occurred because staff did not accept responsibility for the potential safety implications of their behavior and because they calculated that they would not be held accountable. The impact of systemic contextual constraints was to normalize the practice of deviating from recommended procedures.
In order to improve communication and address problems observed in clinical handover, the ECCHo team developed two tools. These brought together the language analysis findings and the systems approach. The tools were:
- iCARE3, a model of effective communication in clinical handover. This is both an evidence based, theoretically motivated model of effective handover communication and a practical tool to achieve better communication. It encapsulates the essential systemic dimensions that affect communication in clinical handover, and provides practical protocols to achieve safe communication. By targeting the critical systemic weak points in the contextual, interactional and informational dimensions of clinical handover – the latent factors or ‘underlying pathologies’ – iCARE3 offers specific strategies to minimize active errors and violations.
- CHARM , a Clinical Handover Assessment and Risk Matrix derived from iCARE3 . This matrix enables clinicians and managers to analyze current practice in their handover contexts, compare current practice with recommended practice, and identify latent risk factors that need to be addressed.
As we show below, these tools are generic enough to be relevant to most handovers, but flexible enough to be adapted to specific contexts.
Tab. 15.1: Classification of communication risks in clinical handovers, drawing on examples from the ECCHo project
15.5Managing communication risks: the iCARE3 model
The iCARE3 model is represented diagrammatically in Fig. 15.3. The model has four components designed to encourage organized and systematically structured handovers: three new protocols (CARE-1, 2 and 3) and the familiar handover protocol iSoBAR. These four protocols are positioned against a background that identifies four key contextual dimensions (participants, scheduling, environment and resources).
In the sections below we begin our explanation of the iCARE3 model by highlighting the need to understand handover practice in its organizational context. By positioning participants, scheduling, environment and resources as the four corners of the model, iCARE3 underscores our interpretation of communicative context as a latent risk factor in handover. Clinicians, managers and policymakers need to manage the communicative context of handover, not simply to persevere in spite of it.
The two strands of informational and interactional meaning in clinical handovers are fundamental to the iCARE3 model. The component CARE-1 is concerned with the quality of information – it stands for Concise, Accurate, Reasoned and Explicit information. Clinicians can deliver this information using a standardized but flexible structure. While we recommend iSoBAR to structure handover, one of the strengths of our approach is that alternative mnemonics and locally derived handover protocols can be easily accommodated within the iCARE3 model.
Finally, and critically, iCARE3 reminds clinicians that handover is an interactive exchange and that all handover communication must therefore be inclusive and other-oriented or ‘recipient designed’. There are two CARE protocols designed to ensure interactivity in both spoken and written handovers.
Fig. 15.3: The iCARE3 model of effective communication in clinical handover
The CARE2 strategies for spoken handover focus on interpersonal exchanges , encouraging clinicians to involve their colleagues and patients interactively in the handover process of effective spoken handovers by prompting them to Connect , Ask , Respond and Empathize .
The CARE3 strategies arise from acknowledging that written handover information also involves interaction – in this case between the writer and future readers. CARE3 reminds those performing written handovers of the need to make these Compliant , Accessible , Readable and Enduring . These CARE3 strategies reinforce compliance with policies on written material (such as the use of approved abbreviations and identification requirements).
In the following sections we explain the components of the model in more detail, before employing them to develop the CHARM handover assessment tool .
15.6Contextual constraints in iCARE3 : participants, scheduling, environment and resources
The ECCHo project found that the hospital environment imposes significant contextual constraints. These constraints impede effective communication and compromise clinical handover. They also contribute to clinicians making accidental errors or intentional violations. We believe that policymakers and practitioners need to acknowledge the possible effect of these contextual constraints on patient safety and better manage them, challenging though that may be given the implications for time and resources. Figure 15.4 captures these contextual dimensions.
15.6.1Communicative context 1: Involving all relevant participants
Handovers are safest when all the relevant team members involved in caring for the patient are present, and when the patient is also present. Patients are at risk when their care is handed over by clinicians who are not familiar with their background, current situation and care plan, or when patients are not included in the handover. At the very least, therefore, the clinician handing over the patient’s care should have directly cared for the patient. The clinician who will be directly caring for the patient next should also be present and able to participate actively in the handover. Wherever possible the patient should also be invited to contribute to the handover. This means that, when possible, a significant part of the handover should be performed at the patient’s bedside.
Attention to participants necessitates cultural and procedural change to avoid the risk practices observed in the ECCHo project. Some of these risks observed were:
–requiring a junior nurse who had just started her shift to transfer to another ward a patient she had never cared for and barely met
–expecting clinicians to operate in circumstances outside their scope of practice
–allowing a doctor to hand over patients she had never seen on behalf of an absent colleague.
If a delegated substitute must perform a handover in place of the relevant direct care clinician, the delegate must take – and be given – time to get to know the patient directly.
15.6.2Communicative context 2: Scheduling
Handovers are safest when the participants can take the time they need to hand over the patient’s care thoroughly. We acknowledge that there are time constraints in many high-stress hospital contexts. However, it takes even more time to sort out complications caused by inadequate or partial handovers, or to resolve misunderstandings and gaps in communication. In addition, patients can be at risk when clinicians rush handovers or feel obliged to compress the handover to fit an inflexible schedule. Organizational and ward management must therefore ensure that clinicians know they can take the time demanded by the patient’s clinical needs to complete the handover. It follows that clinicians performing scheduled handovers (e.g. shift change and ward round handovers) must be allocated a realistic amount of time. The allocation should be based on an empirical assessment of the ward’s needs (see the CHARM assessment tool discussed below). Clinicians performing ad hoc handovers (e.g. when the patient is moved between locations) must also be allowed the time they need.
15.6.3Communicative context 3: Environment
The environment of the hospital ward presents multiple constant challenges to effective handover communication. The shared open space in which clinicians spend most of their working day exposes them to high levels of ambient noise from overhead announcements, equipment, and the presence, movement and conversation of surrounding people. The absence of doors and private rooms means that clinicians are often performing their clinical duties ‘in the open’, susceptible to being interrupted or distracted. A clinician who cannot stand close enough to see or hear the handover, or who is required to answer a phone call or respond to an in-person request mid-handover is a clinician who is not effectively present at the handover. The ‘environment’ dimension of iCARE3 requires management and practitioners to find ways to create a virtual handover room – that is, to achieve a handover space that enables effective handover while respecting the need to involve the patient wherever possible and to be available to respond to clinical emergencies if necessary.
In some cases this can be achieved by moving the handover to a less cramped, better equipped space on the ward. This might be done, for example, by creating a handover corner where the computer monitor is visible to all participants and where there is enough space for all to cluster and hear what is said. Participants’ backs create an artificial wall, discouraging interruptions. In other cases, for example at the patient’s bedside, privacy curtains should be used to reduce the susceptibility to interruption. Other simple strategies that can be used to create a virtual closed space include equipping all the handover team with clipboards. Clipboards become a formal marker that helps reinforce the verbal explanation to would-be interrupters that the group is currently performing handover and should not be distracted unless the need is urgent. Handover participants must also be embargoed from taking mobile phone calls or responding to all but emergency pagers.
Where it is impractical for the group to move from bedside to bedside, a flexible approach for busy, team-based handovers would be for the outgoing clinicians or team leader to brief the incoming team in the designated handover space (facilitating discussion of confidential or team relevant issues). This should be immediately followed by individual outgoing–incoming nursing pairs moving to the patient’s bedside to complete the handover process. In this instance the incoming nurse now leads the interactive discussion by performing ‘readback’ (the final iSoBAR stage, discussed in chapter 9). That is, the incoming nurse confirms with the patient his or her understanding of the information and care plan provided, while the outgoing nurse clarifies or corrects the information as needed.
15.6.4Communicative context 4: Resources
The ECCHo team observed many handovers where patient safety was compromised because team members did not have immediate access to all the information they needed. When patient records are missing or incomplete, when test results and scans cannot be viewed and discussed, or when transferring institutions cannot share documents, the patient’s safety is not being protected. Organizations and practitioners need to find solutions to these common risk-creating problems. Some local solutions may appear simple but in fact require significant cultural change. For example, we rarely observed teams having access to or consulting patient records during handovers. The clinician giving handover typically relied on memory. Where information could not be given, the solution was usually agreement to ‘check later in the patient’s notes’, but this carries substantial risk. By contrast, in the minority of handovers where all documents were available, participants collaborated to produce a comprehensive and well informed handover.
15.6.5Context and handover: summary
A rushed handover that participants cannot hear, delivered by someone who has not cared for the patient, and where key questions about the patient’s status cannot be resolved because records are missing, is not a safe handover. The four contextual dimensions discussed above, identified from the empirical research of the national ECCHo team, identify conditions that management and practitioners need to manage in order to have verbal or written handovers that are as effective as possible.
15.7Effective information is structured information: iSoBAR in iCARE3
Both our research and the literature on clinical handover show that the effective exchange of information is critical in maintaining patient safety. Clinicians must exercise skilled judgement and be highly aware of situations in order to determine just what constitutes the necessary information – the minimum dataset – in their specific context. They must draw on complex communication skills to then communicate this information effectively in both spoken and written handovers.
Our understanding of human factors and effective communication indicate that if people consistently follow a structured sequence, this is an effective way to communicate complex information clearly (ACSQHC 2012a). A structured protocol helps the provider know what information to gather and organize; it helps the receiver to tune in, anticipate, expect, and therefore notice and query gaps immediately. In this way a shared structure minimizes unnecessary interruptions while also avoiding the risks of deferring and possibly forgetting to follow up queries.
Tab. 15.2: The iSoBAR system for effective clinical handover communication
| Avoid this | Encourage this | |
| Concise | All known information about the patient is given. All information on shared written documents is read out. | Information is relevant to ensuring patient’s safety and continuity of care. Information succinctly adds value to any shared written information |
| Accurate | Information has not been updated. Records have not been checked or followed up. | Information is up to date and thorough |
| Reasoned | Provider delivers information as an unordered list of apparently unrelated facts. | Provider offers a causal account – links pieces of information to construct an explanation of patient’s situation and treatment plan |
| Explicit | Vague words: some, a lot, a bit, slightly, somewhat Expressions of doubt and uncertainty: maybe, I guess, perhaps Ambiguous terms used | Information is specific, precise and certain – precise quantities, qualities and meanings provided Provider stands by the information – states clearly what s/he knows or does not know |
The iCARE3 model recommends that clinicians use an adapted iSoBAR protocol when delivering both spoken and written handovers. As shown in Tab. 15.2, we also include prompt questions to help clinicians identify relevant information to hand over in specific clinical contexts.
15.7.1CARE-1 information quality: Concise, Accurate, Reasoned, Explicit
No communication model can teach clinicians what are essentially clinical skills, such as evaluating a patient’s status, reaching a reasoned diagnosis and formulating or carrying out a care plan. However, communication research like the ECCHo project can suggest the qualities that minimum dataset information will have, bearing in mind again the principle of recipient design – the need for information to make sense to listeners/readers who may or may not be present. On the basis of our research, iCARE3 suggests that, in order to prepare for handover, clinicians need to select information with CARE, i.e. by using information that is Concise, Accurate, Reasoned and Explicit.
To select Concise information, the handover provider must determine what information is relevant to ensuring the patient’s safety and continuity of care, given the current clinical context. It is not concise to simply run through all known information about the patient. Nor is it concise to simply verbalize information that is available in a shared printed document, such as a ward sheet. Instead, the giver and receivers need to focus on key indicators and actual or potential changes in the patient’s situation.
Accurate information is up to date and thorough. The giver must prepare for handover by checking any outstanding test results, medication orders and entries in the patient’s record.
By Reasoned we mean that information is not simply presented – either verbally or in writing – as a list of bullet points, with no particular logical connection between them. In a reasoned handover the clinician explains the connections between the pieces of information, often in collaboration with the patient. In this way the clinician builds up a causal account that explains what has happened and needs to happen to the patient, and why the care plan is as it is.
Quality information is also Explicit, that is, specific and precise. Vague language – words like somewhat, sort of, a lot, a bit – or expressions suggesting doubt and uncertainty – I guess, maybe or probably – have no place in a verbal or written clinical handover. When potentially ambiguous information is transferred, the intended meaning should be made explicit by clarifying details.
These information quality characteristics are summarized in Tab. 15.3 below.
15.8Handover as an interactive event: recipient design and iCARE3
As we believe we have demonstrated throughout this book, communication in handover is inherently and inevitably interactive. Whether spoken or written, no handover is a monologue. Handover guidelines and protocols must therefore be based on an informed understanding of how interaction works and how interaction is relevant to achieving effective communication in clinical handovers. In developing iCARE3 we acknowledge two fundamental points about interaction.
The first is that interaction is good for patient safety. The immediacy and reciprocity of interaction mean that problems and errors can be noticed and resolved quickly. However, this will only happen if the participants do actually interact, and that means the patient and the incoming team must be encouraged to ask questions, query, challenge and add information. Far from ‘wasting time’, interaction is highly time-efficient. iCARE3 is one contribution to building awareness and a culture that values interactivity, not passivity, in handover.
Secondly, to communicate effectively, communicators – whether speakers or writers – must shape their message to meet the needs of their listeners or readers, and must be aware of the contexts in which their message will be heard or read. Writers must realize that their potential audience is often both immediate and direct (Dr X will read their notes when the patient arrives on their ward) and also delayed and institutionally diffused (many clinicians will read the notes in various future contexts).
Tab. 15.3: Information quality in clinical handover
| Stage name | Aim | What you need to explain during this stage |
| Introduce & Identify | To introduce yourself by stating the role you’ve played in this patient’s care To clearly and accurately identify and locate the patient |
Who are you? What has been your role with the patient? For how long? Who is the patient? (Use approved patient identifiers) How old is the patient? Under which consultant? When did the patient arrive at the hospital/ward? In which bed is the patient? |
| Situate | To explain the patient’s presenting condition and diagnosis | What brought this patient to the hospital this time? What is the provisional diagnosis for this patient? What is the patient’s current clinical condition? (stable/deteriorating) What are the current concerns or priorities for this patient? Have there been any marked changes or issues during your care that the incoming team needs to know about? |
| Observations | To state the patient’s recent relevant vital signs and clinical assessment | What observations have you made/taken that need to be handed over? What relevant clinical results are available? Is there evidence of deteriorating condition from vital signs, examination, tests or scans? How has the patient been feeling? (Ask the patient) |
| Background | To hand over the patient’s medical and social background relevant to this admission | What medications, allergies and alerts do you need to hand over? What relevant parts of the patient’s medical history do you need to hand over? What social, familial or other non-clinical information do you need to hand over? Which clinical teams have reviewed the patient or are yet to do so? What is the status of relevant clinical or care tasks? (highlight tests, scans, daily care not completed) What results are still outstanding? |
| Agreed plan | To explain the treatment plan for this patient To clearly hand over accountability and responsibility for ongoing care of the patient To highlight any risks to the patient |
What is the current treatment plan for this patient? What further reviews and tests is the patient scheduled to receive and when? What actions do handover recipients need to take to ensure this patient’s continuity of care on the next shift? (Specify who must do what when) What are the potential risks associated with the treatment plan for this patient? |
| Readback | To verify that the receiver of the handover has heard and understands what is required and accepts responsibility for the patient To give handover participants the opportunity to check or query any aspect of the handover |
Have you checked for shared understanding of the information with your colleagues and patient? Has the individual or team taking over explicitly accepted care of the patient? Does the patient have any information to add or request? |
The iCARE3 model reflects the safety value of interaction by applying the CARE acronym to both spoken and written documents supporting handovers, as we will now briefly explain.
15.8.1CARE-2 in spoken handovers: Connect, Ask, Respond, Empathize
In spoken handovers, the CARE-2 protocol supports clinicians to involve their colleagues, the patient and carers in the handover, as discussed more fully in chapters 6 and 7). The components of Connect, Ask, Respond and Empathize capture the essential components of an interactive spoken handover – one that recognizes the presence and contribution of all those attending the handover.
Connect encourages all handover participants to greet patients and one another, introduce themselves and explain the purpose of the handover.
Ask encourages clinicians to participate actively in the handover by querying, checking or asking each other for further relevant details. It also encourages clinicians to include the patient in the handover, wherever possible. ‘Asking’ requires the clinician to be assertive but not aggressive.
Respond encourages clinicians to react non-defensively to whatever their colleagues or patients say. It sets the expectation that the handover will be an interactive process in which participants are willing and prepared to respond appropriately to the queries and contributions of others.
Empathize encourages clinicians to recognize the professional abilities and interpersonal needs of their colleagues. Importantly, it calls on clinicians to respect the patient’s interpersonal needs for privacy, reassurance and inclusion. Clinicians should not ignore or patronize each other or their patients; nor should they publicly share information which a patient may find sensitive, embarrassing or culturally inappropriate.
Through its use of the Connect, Ask, Respond, Empathize protocol, the iCARE3 model makes clinician engagement and patient involvement core components of all handover communication. In chapter 7 we outlined specific language strategies for clinicians to use to achieve these dimensions of CARE. At the bedside, implementing CARE-2 is relatively straightforward – short, targeted training is often enough to give clinicians the confidence to involve the patient. However, even in those cases where patient exclusion is unavoidable – such as in mental health contexts or where patients are unavailable, too ill or too distressed to participate – the CARE-2 principles can still be applied. We recommend that in such circumstances clinicians use CARE-2 to prepare for a handover, by connecting with the patient, family members or carers to find out information and hear their questions, opinions or anxieties. Clinicians can then represent the patient’s point of view in the handover – as we saw the mental health professionals doing in chapter 13 – and report back to the patient when appropriate. In this way the patient’s voice is still included in the handover and patients are participants in the interaction about their care.
15.8.2CARE-3 in written handovers: Compliant, Accessible, Readable, Enduring
Documents that support effective handover need to be interactively designed so that non-present recipients can understand them at some future time, potentially as both givers and receivers of information. CARE-3 acknowledges this, and calls for handover documents that are Compliant, Accessible, Readable and Enduring.
To be Compliant, all electronic and written documents used to support handover need to adhere to the standards and procedures of the health services and professional bodies concerned. This includes the use of approved abbreviations and rules for both clinician and patient identification. Clinicians need to provide the right documents and to use them in the ways mandated.
Accessible documents are available to all who need them, at the time they need them, and in language that is easily understood by the intended readership. Accessibility manifests at two levels. Firstly, physical accessibility means that relevant, up-to-date information should be immediately at hand. Second, deferred accessibility means that that the writer considers the potential future readership and the needs and capabilities of those who will use the information. To achieve accessibility, clinicians must not use language that excludes people.
Readable documents are legible, interpretable and searchable. Whether in electronic or paper form, charts, forms and checklists must provide enough space for accurate and legible completion and must include clear instructions about how they should be completed. Acronyms and abbreviations should be avoided in both design and completion if there is any potential for ambiguity. Illegible writing is ultimately inefficient and ineffective.
By Enduring we mean both that documents are written to last and that they are written to be interpretable by a non-present other, i.e. that the meaning endures beyond the time of creation. They are not scraps of note paper slipped loosely into a folder and likely to fade or slip out. Because the written context restricts the immediacy of feedback, the writer must predict the reader’s need to know, and try to anticipate the reader’s queries by providing enough information and justification to explain recommendations and instructions, rather than just listing them. Handover information must therefore be both materially durable and context-independent.
By writing documents that are Compliant, Accessible, Readable and Enduring, those giving a handover can ensure that their message is conveyed effectively across boundaries of space and time within and between institutional settings. Chapter 9 provides an extensive discussion of these points.
15.9iCARE3 as a response to accumulating risks across the patient’s journey
We began the chapter by noting the problem of risks accumulating across a single handover event. In other chapters we have noted risks accumulating across sequences of mixed interactions – consultations, handovers, referral letters, transfer documentation, etc. As we have noted repeatedly, clinical handovers are not isolated events but are embedded in the sequence of interactions that constitute the patient’s journey through the hospital. The quality of any one of a patient’s clinical handovers is affected by the quality of the clinical interactions that surround the handover (e.g. consultations, clinical discussions, team meetings). We have argued that efforts to improve handover communication must acknowledge the interconnectedness of interactions and address communication problems beyond the boundaries of clinical handover.
The iCARE3 model, focused as it is on the event of clinical handover, does not address this issue directly. However, by conceptualizing strong clinical handover practice it indirectly requires clinicians to repair omissions and deficiencies in the interactions that have led up to the handover. Further, the CARE-1, CARE-2, CARE-3 and iSoBAR protocols offer powerful tools that clinicians can use to manage the dual informational and interactional dimensions of all clinical interactions.
In the following section we explain how to apply the iCARE3 model as an assessment tool, to evaluate the effectiveness of existing handovers.
15.10Clinical handover assessment and risk matrix (CHARM)
To improve their handover practice, organizations and clinicians first need an accurate understanding of where the risks are occurring in the range of handovers they are involved in. To achieve this understanding, someone needs to stand ‘outside’ the handover event and evaluate it from beginning to end, just as we did with the handover of Indira described at the start of this chapter and the many others observed, recorded and described throughout this book. We suggest that assessing handovers against iCARE3 components is one way to achieve this.
Below, we set out a framework based directly on iCARE3 that practitioners can use to assess their current handover practice. We explain the motivation for associating a particular way of delivering handover (a handover modality) with the reasons for doing the handover (handover types). To do this we use the categories of handovers from the Australian clinical handover solutions matrix (ACSQHC 2012a) and clarify the aims of each handover type. We then explain the relationship between the goals of handover and the iCARE3 contextual dimensions of participants, schedule, environments and resources. Table 15.4 shows the suggested practice in handovers of different types, according to handover purpose, handover modality, participants, schedule, environment and resources. As a first step in assessing their practice, teams can compare their actual handover practice with that suggested in Tab. 15.4. As a second step, we offer a suite of questions derived from iCARE3 that teams can use to evaluate existing handover practice.
Tab. 15.4: Recommended handover contexts and modalities
15.11CHARM questions
15.11.1Purpose of handover
–Is the purpose of the handover clear to all involved?
–Is the type of handover likely to achieve the aims?
–Is the method of delivering the handover appropriate to the purpose and aims? (‘appropriate handover modality’)
15.11.2Assessing contextual risks
15.11.2.1Participants
–Are the necessary participants present throughout the handover?
–If necessary participants are not present, who is missing? For how much of the handover? Why? Is this absence a one-off or a recurrent problem?
–Are some necessary participants called away or distracted during the handover?
–What needs to change to make sure the relevant participants can be present throughout the handover?
–Is one participant recognized as the designated handover mentor or supervisor, responsible for ensuring the quality, comprehensiveness and accessibility of the handover? If not, what needs to change to make this happen?
–Are any participants being obliged to accept or hand over care that is outside their scope of practice?
–In team-based distributed care delivery, handover participants who have not had personal contact with the patient may be delegated to represent a colleague or team. For example, a junior medical officer may be asked to complete discharge documentation. How is information integrity maintained and duplication of tasks minimized in such circumstances? Is the transfer of responsibility effectively coordinated and tracked?
15.11.2.2Scheduling
If the handover is a scheduled one (e.g. shift change):
–How much time has been allocated for the handover? Is this adequate time?
–If not, what would need to change to ensure adequate time?
If the handover is unscheduled but anticipated (e.g. discharge):
–Was adequate time allocated for all elements of the handover (verbal handover to patient/ carer, written transfer letters to community care etc.)?
–Was the patient kept waiting in a discharge area? Why? For how long? Could this have been minimized?
If the handover is unscheduled and unanticipated (e.g. deterioration):
–Was it possible to organize the handover rapidly enough?
–If not, how could delays in organizing it be avoided?
Was the handover occurring at a high-risk time (e.g. weekend, night time, public holiday)? If so, what protections were in place to manage possible unscheduled transitions or reduced access to specialists?
15.11.2.3Environment
Where is the handover taking place? Is this space:
–large enough to accommodate all participants?
–organized in a way that enables all participants to be part of the handover? (see and hear one another and the patient)
–able to allow patient/carer involvement in the handover? If not, why not? How will patient involvement be arranged?
–quiet enough for all participants to hear the handover and the patient/carer’s comments?
–protected from interruptions?
–private enough to enable the handover of non-confidential information? (e.g. privacy curtain at bedside)
–private enough to enable the handover of confidential/ sensitive information be handed over, such as a staff-only area?
–If not, how can the environment be modified?
15.11.2.4Resources
Do the participants have the paper-based and computer-based resources they need to achieve the handover? These might include:
–patient’s records for this admission
–handover sheet
–current observations chart
–current medication chart
–test results for this admission
–team review comments
–allied health reports
–patient history – electronic records, GP referral, etc.
If not, why not?
15.11.3Assessing informational risks
Does the provider present the handover in the iSoBAR sequence, i.e.:
–Introduce and Identify, Situation, Observations, Background, Agreed Plan, Readback
Is the information of appropriate quality – is it:
–Concise: relevant and adding value to other shared material?
–Accurate: up to date and thorough?
–Reasoned: an explanation not just a list?
–Explicit: specific, precise and certain?
If no to any of these, why not? And what would need to change for the handover to meet these requirements?
15.11.4Assessing interactional risks
In face-to-face spoken handovers do clinicians:
–Connect with the patient and other handover team members during the handover (e.g. in bedside handover)?
–Ask colleagues and the patient for input? If not, is the patient’s involvement sought before the handover and incorporated into the handover?
–Ask one another for clarification and confirmation?
–Respond to patient questions and questions from receiving team members, either immediately or through later interaction with the patient?
–Empathize with the patient’s concerns, needs and sensitivities, either immediately or by later interaction with the patient?
If no to any of these, why not? And what would need to change for the handover to meet these requirements?
In written handovers, are written handover documents:
–Compliant: meeting all mandated policies and protocols?
–Accessible to all present or all who need them, when they need them?
–Readable: both legible and interpretable?
–Enduring: materially durable and context-independent?
If no to any of these, why not? And what would need to change for the handover to meet these requirements?
15.12Conclusion
Throughout the three years of the ECCHo project, all the ECCHo team members at the four sites across Australia were continually impressed by the professionalism and commitment of clinicians and the trust and goodwill of patients. We recognize that healthcare professionals do their best to provide safe, satisfying health care in highly challenging contexts. The doctors, nurses and psychiatrists we observed and recorded dealt for the most part courteously and compassionately with patients from diverse backgrounds and with complex needs and conditions.
However, the statistics on iatrogenic patient harm cited in various chapters of this book are sobering and show few signs of improving. We believe that the iCARE3 model we have presented in this chapter can make an impact by providing an evidence-based, explicit, adaptable and pragmatic model of effective communication in clinical handover.
Our iCARE3 model brings together the findings from the diverse research sites. All the material in this book is based directly on the interactions we saw and heard, and the documents we read, in real hospital contexts. This empirical data of actual behavior by real people working under the daily stresses of hospital routines gives unique insights into the many challenges of contemporary hospital care. The interprofessional, translational approach of the ECCHo research – drawing on expertise from linguists, human factors specialists, doctors, nurses, psychiatrists, policymakers and managers – has allowed us to develop accounts and resources that are grounded and have been tested in real workplaces.
All the chapters of this book, and of course the iCARE3 model itself, depended on the willing participation of hundreds of people around Australia. At each research site we were welcomed by managers, clinicians and patients, all of whom generously agreed to participate in the research because they recognized the central role communication plays in achieving safe health care. We hope and believe that the research presented in this book justifies the participants’ faith in us, and we express our gratitude for their vital collaboration in helping us make communication in clinical handover more effective.