A Study Of Handover At Shift Changeovers In Care Homes For .

A study of handover at shiftchangeovers in care homes for olderpeople“It's part of our job. It's part of our care and we can't do right and good care ifwe don't have [] handover”. CH4, I2 RNResearch TeamCaroline Norrie caroline.norrie@kcl.ac.ukRekha Elaswarapu rekha elaswarapu@yahoo.co.ukValerie Lipman Valerie.Lipman@ kcl.ac.ukJill Manthorpe Jill.Manthorpe@kcl.ac.ukJo Moriarty Jo.Moriarty@kcl.ac.ukKing’s College London,Research Ethics CommitteeRef: LRS15/162118

Aims and BackgroundAims:Investigate the content, purpose and effectiveness of the handoverof information between two different sets of care home staff.Background: anecdotal evidenceQuestions: How are changes in individual residents’ needs, wishes andcircumstances communicated between shifts? What are the dynamics between the staff giving and receivinghandover? What are considered by staff and stakeholders as key elements ofan ‘effective’ handover in a care home?

Methods1) Literature review2) Case-studies in 5/6 Care HomesIn each:Interviews (n 6) and Observations (n 2/3)3) Focus group with SCWRU service user advisory group(n 15) and additional stakeholder interviews (n 2) Experienced care assistant Employee of company supplying care homes withelectronic care plans and handover systems

1)Literature review – backgroundStudies address:- Studied extensively in the Poor handovers - one of thehospital clinical settingsmajor contributors towith nurses and doctors andmedication and diagnosticerror /accidents/delays/poortransfers (e.g. betweensafety/ poor patient satisfaction.home and hospital). Face-to face/verbal/notes/IT Little attention to carehomes and non-nursingstaff. Where handovers take place (egbedside or over-computer) Guidelines/Standardised models(eg verbal SBAR or H-T-T) Other functions of handover - eginformation, social andeducational

Literature review – handover in care homes(16 studies identified/ 5 meet criteria)1) Tariq et al. (2015) exploredrecords from three residentialhomes in Sydney, Australia, andfound that poor handoverscontributed to prescribing errors.3) Zhang (2011) Australia - staffopinions on benefits ofintroducing an electronic recordsystem (positives).4) Gaskin et al. (2012) –Information exchange in 5 care2) Lynhe et al, (2012) Hybridpaper/electronic system in a care homes in Australia. Ranged fromall paper to paperless (mobilehome in Australia. Foundduplication of information, a lack devices). IT has the potential toenhance handovers, in careof standardisation and a lack ofobvious guidelines and protocols homes. But complex – someunexpected outcomes – actuallyand information sources.Electronic systems have potential. increased documentation timeor made no difference.

Literature review – handover in care homes(16 studies identified/ 5 meet criteria)5) Wheeler and Oyebode (2010) explored the quality andeffectiveness of communications for people with dementia innine homes in the West Midlands using staff focus groups. They found that handovers typically took place three times aday, were brief, relaying only pertinent information from theprevious shift. In one third of homes (3), handovers only involved the seniorcarers (care workers) on duty, although in one home a keyworker system was in place for handovers. They also reported some homes as having separate handoversfor nurses and healthcare assistants and ‘demarcation’ wasseen as a potential source of conflict.

Lit review – CQC CQC says handoversCQC guidance forare an important tool forproviders –assessing lots of thingshandovers(e.g. safety, effectivereferenced 14 times communication, workingtogether, personas part of the Keycentred routines) – butlines of enquiryno guidance that says(KLOEs) (CQC 2015). what constitutes goodpractice.

Case-study sitesSite 1) Independent Family home - (residents 50) Family-run. Mostlypaper.Site 2) Small chain - (residents n 60 residents). It is part of a chain ofthree homes which are independently managed. Hybrid; care planselectronic, other documentation paper.Site 3) Small privately owned/ voluntary not for profit (residents n 26).Site 4) Part of a large well-known Chain (residents n 100) Gujaraticlientele. Hybrid; care plans electronic, other documentation paper.Site 5) Small privately owned (residents n 22) - Staff use mobilephone application to update daily handover notes at point of care.

Analysis - variations in handoversCare Home 1Timings?Who hands over?Location?8amRN hands over to RN;RN to CANurses station/ orMostly paper Systematicwalk around room byroom.9am (sometimes)(If room by room,Nurses handover to CAsCAs listen outsideafter breakfast.the door no need for9am handover)2pm (sometimes)8pmHandover to CA comingon.ProcessesContent

Analysis - variations in handoversCare Home 2Timings ofhandovers8amWho hands over?Location?ProcessesContentNight RN to all staff(RNs and CAs)Nurses station / staffroom if confidentialityneeded.Mostly paper12 middayDay RN to all staff at12am.Systematicdiscussion ofall residentsfollowingprinted sheetwith namesand inputs/outputs.8pmCAs to RN throughoutday. Day RN handsover to night CAs.Allocation ofresidents tostaff afterhandover.

Analysis - variations in handoversCare Home 3Timings ofhandoversWho hands overs? Location?Processes7.45amAll staff (day and Manager’s officenight shift) and theManager.Hybrid;(2 Extra staff so allcan attend in am)7.50pmCAs handover to 2Seniors;Seniors handover to2 night staff.ContentExceptionCare plans electronic, reportingother documentationpaper

Analysis - variations in handoversCare Home 4Timings?Who hands over?Location?7.45/8amRN to RN by room;then RN to CAs (staffoutside door, unlessresidents already up).(Extra staff so all canattend in am)Room by room unless Hybrid;residents are up in Care plans electronic,which case it can be other documentationflexible.paper7.50pmCAs hand over to SCAbefore they leavetheir shift. Then SCAhands over to nightRN. Night RN handsover to afterhandover.

All staff perspectives on handovers – purposeand effectiveness –‘it’s part of the job’ Handovers - Intrinsic part of the jobSo I know it's part of the job and I assume they know it's part ofthe job. So it's duty-bound. (CH3, I5, CA). Communication enables improved continuity and safetyof residentsIt’s a rolling and on-going thing. If a staff member was off for 3days and if a resident is on antibiotic and should not be givenmilk, the concerned, caring staff should know about it. So if thisinformation is not handed over then it is risky. To keep residentssafe. Saves staff from just carrying on without considering thechanges but helps to personalise care. (CH3, I2, CA)

Manager and RN perspectives onhandovers – purpose and effectiveness Mangers and RNs also interested in: TeambuildingPersonnel issuesStaff trainingRNs also more focused on clinicalissues/medicines.

Managers - strategic overviewMainly to know they're working as a team, not just information. And also to. makingsure everybody's fine and happy. [] I've sent people home sick because they come inbecause they didn't want to[]. It's nice to see the staff, to even ask if they've had a niceholiday or whether they've got any concerns.[] I can ask them to see me afterwards, orthey may want to see me afterwards about some sort of personal issue.(CH3, I1,manager)I would empower people, as well, that they feel integrated into the handover and makesure that they are integrated. I don't like it if the handover is too like an exam class,like everybody's tired. Just make it a bit more conducive to learning, stimulating; I likethat kind of handover. (CH2, I2, RN)I think the fact is that they're now structured. It is at the start of the shift. But also, Ithink we've not just been static in the eight o'clock shift as well. We can do a handoverbetween. even during the day, so if we want something the actual. the nurses know,so if I come along at, say, 12 and say, right, handover to me, they know what to saybecause they've got the sheets, they've got the information, because they know it'sexpected, so I think the good thing about it is that they've developed themselves, sothe staff have developed themselves. (CH4, I1, Manager)

CA perspectives on handovers - purpose andeffectiveness‘I’m not going into the wilderness!’ Also: Resident safety paramount Being prepared – ‘I’m not going into thewilderness!’

CA perspectives on handovers - purposeand effectiveness These old people, all 80, you know, 80, 90, we have 100 years old.101. You don't know any five minute, anything happen. Because Ihave experience here, so that's why. It's good, you know, in themorning and before you leave and you check all over and they'refine. They're fine, yeah. (CH4, I6, CA) we could be on annual leave for two or three weeks; there's beenchanges, so we may go to the floor and we don't know nothing, so Ithink the handover is very, very important, especially if we've got anew service user, that service user could have come in at fouro'clock. I'm not here, so I know nothing about that person, which Ineed to know because, doing breakfast, I need to know if they'rediabetic, if they're on puree, if they can have cornflakes. (CH2, I1,CA).

Families’ perspectives (SWCRU advisory group) Handover notes allow the resident’s representative to check ‘what’spaid for is being provided’ and the agreed care plan is beingimplemented. Handover notes assist following up on issues if necessary. Handover notes help provide a measure of quality of life of the carehome resident. Handover notes were crucial in charting a resident's progress andenabling the family of a resident to request a review of a carepackage (which one participant complained would not occurotherwise for his relative.) - ‘the only way to do this is from herrecords’.

Key elements of an effective handover taken frominterviews with different staff groups, stakeholdersand service-user group –“So we have to be punctual, we have to listen carefully, we have to follow it up and we have tohandover to the others as well when they come”. (CH2, I4, CA) Handovers are viewed as importantby management Opportunity to ask questions;feedback from all attendees notignored Timeliness encouraged Being able to listen/hear i.e. nottoo many distractions orinterruptions Confidentiality of clients respectedand dignity respected Production of transparent andavailable written records (allowfamily to review and monitorquality of life changes) Guidance on handover availableand known to staff Open discussion about variablesabout handover and what suitscertain care homes or whetherflexibility acceptable E.g. timing,location, who hands over to who,participation, content.

Decisions about timing, attendees, duration andlocation have implications for residents’ safety/safeguarding Timing of handovers – A ‘continuous’ processthroughout shift or something that happens at the end? Duration – speed versus thoroughness? Content – exception reporting or systematic approach? Who hands over to who/ Attendees – balance betweenteam building when all staff attend versus speed ofhandover if RNs and CAs handover separately? Need to balance risk of staff attending handover andresidents being left alone (costs of providing shift crossover to ensure all can attend versus staff not being paidfor handovers). Location – room by room may improve safety but timeconsuming (which also has safety implications).

Relevance for safeguarding cases If doing an investigation in ahome, don’t assumehandovers will be the same– they are variable withimplications for practice. Understanding the cultureof the home – arehandovers personalisalisedor is it a mechanisedprocess?(Implications of usingelectronic devices? See datafrom CH5 to come). Handover documents vary,but can be a good source ofinformation aboutmonitoring of residents e.g.pressure ulcers – do notescorrelate with allegations? If handover notes are notavailable, is informationupdated in care plans orelsewhere?