Handover of Care

Topic Editors - Morris Gordon, Jennifer Stojan, Ciaran Grafton-clarke, Elaine Hill and Michelle Daniel

Frequently asked questions

Handover of Care

What is handover of care?


Handovers (or handoffs) can be defined as the transfer of patient information and responsibility from one health care provider to another during a transition of care. This can occur across many different settings (e.g inpatient to inpatient provider, inpatient to outpatient provider). Although handovers have always existed, recently there has been an increase in attention paid to them with a push to instituting formal handover curricula largely due to the following:

  • Handovers were found to lead to communication failures, uncertainty in patient care, delays in diagnosis and treatment, near misses, and redundancy and inefficiencies.
  • Both the Joint Commission and the World Health Organization (WHO) recommended that health care organizations develop a standardized approach to handoff communication and incorporate handoff training into their curriculum.
  • The UK Department of Health seminal report ‘An organization with a memory’ found lack of face to face handover a key element in a number of high profile adverse events, with this one of the priority areas for action.
  • The US Joint Commission identified lapses in communication as the leading cause of sentinel events in their 2007 Report on Quality and Safety.
  • Limiting the time that health care workers can work; the American Council of Graduate Medical Education’s (ACGME) postgraduate work hour restrictions led to the unintended consequence of increasing patient handovers.
References AGCME (2017) Common Program Requirements, Accreditation Council for Graduate medical Education. Available at: https://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements (Accessed: 12 March 2019). Department of Health (2000) An organisation with a memory: report of an expert group on learning from adverse events in the NHS. London: Stationery Office. Available at: https://www.aagbi.org/sites/default/files/An%20organisation%20with%20a%20memory.pdf. (Accessed: 12 March 2019). Horwitz, L. I., Moin, T., Krumholz, H. M., Wang, L., et al. (2008) ‘Consequences of Inadequate Sign-out for Patient Care’, Archives of Internal Medicine, 168(16), pp. 1755–1760. https://doi.org/10.1001/archinte.168.16.1755. Royal College of Physicians and Surgeons of Canada (2015) CanMEDS 2015 Framework. Available at: http://canmeds.royalcollege.ca/en/framework (Accessed: 12 March 2019). The Joint Commission (2007) Improving America’s hospitals: the Joint Commission’s annual report on quality and safety 2007. Oakbrook Terrace, IL: The Joint Commission. Available at: https://www.jointcommission.org/assets/1/6/2007_Annual_Report.pdf (Accessed: 12 March 2019). WHO (2007) ‘Communication during Patient Hand-Overs’. World Health Organisation. Available at: https://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf. (Accessed: 12 March 2019).




Why is ‘specific education’ needed?


The Joint Commission and the World Health Organization raised awareness for the need of formal handover training and standardization to improve consistency and reduce vulnerability to errors. The Association of American Medical Colleges (ACGME) also emphasized the importance of handover education and assessment by including handovers as a core entrustable professional activity (EPA) prior to entering post-graduate training. In the UK, numerous specialty specific training programmes include required work based assessments on handover, with no specific teaching guidance. Handover improvement often focusses on systems and processes, such as mnemonics, templates and web-based resources, but not neccesarily education on how to employ them or how to complete effective handover. Research has shown that, when done well, handover education can be effective, improving trainee confidence, knowledge and skills surrounding the handover process, and even improving health outcomes. Further reading Englander, R., Flynn, T., Call, S., Carraccio, C., et al. (2014) Core Entrustable Professional Activities for Entering Residency - Curriculum Developers Guide. Washington DC. Available at: https://members.aamc.org/eweb/upload/core%20EPA%20Curriculum%20Dev%20Guide.pdf (Accessed: 28 February 2019). Gordon, M. and Findley, R. (2011) ‘Educational interventions to improve handover in health care: a systematic review’, Medical Education, 45(11), pp. 1081–1089. https://doi.org/10.1111/j.1365-2923.2011.04049.x. Gordon, M., Hill, E., Stojan, J. N. and Daniel, M. (2018) ‘Educational Interventions to Improve Handover in Health Care: An Updated Systematic Review’, Academic Medicine, 93(8), pp. 1234–1244. https://doi.org/10.1097/ACM.0000000000002236. WHO (2007) ‘Communication During Patient Hand-Overs’. World Health Organisation. Available at: https://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf. (Accessed: 3 March 2019).




What theory underpins handover education?


Handover performance can be improved through structured and evidence-based education. Unfortunately, a proportion of handover education interventions fail to demonstrate theoretical and pedagogical frameworks and demonstrate significant variability in the delivery of education and method of assessment. A previously published model describes three pillars of handover education represent a significant theoretical tool in the development of education. The constituent theories of egocentric heuristic, agency theory and coordination have implications for education design, delivery and assessment. Additionally, Gagne’s nine events of instruction presents a useful framework in which to develop an effective learning process. A general model of learning non-technical skills, the SECTORS model, has also been applied to the handover context to guide educational design. This model links the elements of Systems and technology use, Error awareness, Communication and Teamwork skills. It describes through Observation and simulation focused pedagogy higher level personal analytical skills of Risk assessment and Situational awareness) References Darbyshire, D., Gordon, M. and Baker, P. (2013) ‘Teaching handover of care to medical students’, The Clinical Teacher, 10(1), pp. 32–37. https://doi.org/10.1111/j.1743-498X.2012.00610.x. Gagne, R. M. (1970) T he conditions of learning, 2nd ed. Oxford, England: Holt, Rinehart & Winston (The conditions of learning, 2nd ed). Gordon, M., Hill, E., Stojan, J. N. and Daniel, M. (2018) ‘Educational Interventions to Improve Handover in Health Care: An Updated Systematic Review’, Academic Medicine, 93(8), pp. 1234–1244. https://doi.org/10.1097/ACM.0000000000002236. Gordon, M., Box, H., Farrell, M. and Stewrt, A. (2015) ‘Non-technical skills learning in healthcare through simulation education: integrating the SECTORS learning model and complexity theory’, BMJ Simulation and Technology Enhanced Learning, 1(2), pp. 67–70. https://doi.org/10.1136/bmjstel-2015-000047. Junior Doctors Committee (2015) Safe handover: safe patients. Guidance on clinical handover for clinicians and managers. Available at: https://www.bma.org.uk/-/media/files/pdfs/practical%20advice%20at%20work/contracts/safe%20handover%20safe%20patients.pdf?la=en (Accessed: 12 March 2019). WHO (2007) ‘Communication During Patient Hand-Overs’. World Health Organisation. Available at: https://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf. (Accessed: 12 March 2019).




What learning objectives should handover curricula accomplish?


  • Describe why lapses in communication are a leading root cause of sentinel events
  • Outline how poor quality handovers can impact patient care
  • Recognize situational factors that can impact the quality of handovers (e.g. time pressures, power differentials)
  • Develop a standardized approach for transitions of care from one health care provider to another (e.g. change-of-shift, unit-to-unit) using mnemonics (e.g. SBAR, I-PASS)
  • Demonstrate the ability to discriminate between essential and non-essential information, that must be communicated to ensure safe patient care
  • Give and receive an effective handover at change of shift
  • Illustrate sound communication practices (e.g. asking clarifying questions, check backs)
Further reading Starmer, A. J. M., O’Toole, J. K. M., Rosenbluth, G., Calaman, S., et al. (2014) ‘Development, Implementation, and Dissemination of the I-PASS Handoff Curriculum: A Multisite Educational Intervention to Improve Patient Handoffs’, Academic Medicine, 89(6), pp. 876–884. https://doi.org/10.1097/ACM.0000000000000264. Wang, D., Sabri, E., Krmpotic, K. and Lobos, A. (2014) ‘137: Using SBAR (Situation, Background, Assessment and Recommendations) to Improve Resident Communication’, Paediatrics & Child Health, 19(6), pp. e83–e83. https://doi.org/10.1093/pch/19.6.e35-134. WHO (2007) ‘Communication During Patient Hand-Overs’. World Health Organisation. Available at: https://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf. (Accessed: 12 March 2019).




What pedagogical methods are used to teach handover?


The full range of methods a clinical teacher would expect have been used. Snowballing and similar excises have been employed in several published interventions to explore handover outside of healthcare, with this method being used to level out Inteprofessional preconceptions and often act as a precursor to practical activities. Key has been methods that allow relevant mnemonics (e.g. I-PASS, SBAR) to be used in a situated context, often through simulation and role play. It is worth noting that without such education, these mnemonics are often misused as simple information organisation systems. As per the details below, it is how they are used that must be developed in teaching. If the example of SBAR is taken, in its NAVY origins, a full report should never take more than 20 seconds. However, in health practice this is rarely, if ever, given as guidance and as such the value of a focused mnemonic tools can be lost.

Handover of Care I-PASS table​

Further reading Gordon, M., Hill, E., Stojan, J. N. and Daniel, M. (2018) ‘Educational Interventions to Improve Handover in Health Care: An Updated Systematic Review’, Academic Medicine, 93(8), pp. 1234–1244. https://doi.org/10.1097/ACM.0000000000002236. Starmer, A. J. M., O’Toole, J. K. M., Rosenbluth, G., Calaman, S., et al. (2014) ‘Development, Implementation, and Dissemination of the I-PASS Handoff Curriculum: A Multisite Educational Intervention to Improve Patient Handoffs’, Academic Medicine, 89(6), pp. 876–884. https://doi.org/10.1097/ACM.0000000000000264. Wang, D., Sabri, E., Krmpotic, K. and Lobos, A. (2014) ‘137: Using SBAR (Situation, Background, Assessment and Recommendations) to Improve Resident Communication’, Paediatrics & Child Health, 19(6), pp. e83–e83. https://doi.org/10.1093/pch/19.6.e35-134.




What learner groups is handover of care best delivered to?


It is appropriate at undergraduate and postgraduate levels for any healthcare professionals who are involved in transferring information and responsibility for patient care between healthcare staff and settings. Handover education should ideally be multi-professional to reflect the reality of clinical practice, aid communication between practitioners and improve patient safety standards. It is also important for addressing communication across and within professional hierarchies. However, published evidence indicates that most handover education occurs in mono-professional groups, so multi-professional approaches are currently rare. More recent published interventions have highlighted the role of such authentic, rather than simulated, multiprofessional teams as the cornerstone of such teaching interventions. This has been demonstrated to be a key method in simulation of handover to address the key theoretical learning elements discussed previously and is not seen using simulated teams. Whilst this presents pragmatic challenges, this is a key element to try and incorporate. Further reading Ebben, R. H., van Grunsven, P. M., Moors, M. L., Aldenhoven, P., et al. (2015) ‘A tailored e-learning program to improve handover in the chain of emergency care: a pre-test post-test study’, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 23(1), p. 33. https://doi.org/10.1186/s13049-015-0113-3. Gordon, M., Hill, E., Stojan, J. N. and Daniel, M. (2018) ‘Educational Interventions to Improve Handover in Health Care: An Updated Systematic Review’, Academic Medicine, 93(8), pp. 1234–1244. https://doi.org/10.1097/ACM.0000000000002236. WHO (2007) ‘Communication During Patient Hand-Overs’. World Health Organisation. Available at: https://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf (Accessed: 12 March 2019).




How do we assess handover performance?


It is important to have available tools that can be used to assess the competency of handover participators. Validated tools can be used by educators and clinical providers to ensure students and clinical workers are competent in this important skill, and to also assess the impact and sustainability of interventions to improve the handover process. An externally validated educational evaluation tool, the handover CEX, is used widely to assess the performance of the handover provider and recipient. This handover CEX assesses six domains on a 9-point scale: setting, organisation, communication, content, judgement and professionalism. There is a range of other assessment tools used to assess attitudes, confidence, knowledge and skills relating to handover, often in the context of evaluating the impact of educational interventions. While a few of these are externally validated, most are designed in response to specific local education programmes without dissemination and external validation. Despite this lack of published evidence, many such tools are incorporated into standard assessments, such as OSCEs and as such use the variety of global and point rating scales employed within these assessments. Additionally, within the UK, several postgraduate colleges have work based assessments which are requirements across all trainees and use similar items as on the handover CEX. There are currently no other disseminated tools or methods in widespread use. Further reading Gaffney, S., Farnan, J. M., Hirsch, K., McGinty, M., et al. (2016) ‘The Modified, Multi-patient Observed Simulated Handoff Experience (M-OSHE): Assessment and Feedback for Entering Residents on Handoff Performance’, Journal of General Internal Medicine, 31(4), pp. 438–441. https://doi.org/10.1007/s11606-016-3591-8. Gordon, M., Hill, E., Stojan, J. N. and Daniel, M. (2018) ‘Educational Interventions to Improve Handover in Health Care: An Updated Systematic Review’, Academic Medicine, 93(8), pp. 1234–1244. https://doi.org/10.1097/ACM.0000000000002236. Horwitz, L. I., Dombroski, J., Murphy, T. E., Farnan, J. M., et al. (2013) ‘Validation of a handoff assessment tool: the Handoff CEX’, Journal of Clinical Nursing, 22(9–10), pp. 1477–1486. https://doi.org/10.1111/j.1365-2702.2012.04131.x.





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