The clinical decision unit (CDU) at the Queen Elizabeth Hospital in Birmingham consists of 68 level-1 beds and 4 level-2 beds. The CDU also runs an ambulatory clinic alongside the main unit, with an average take of 100 patients every 24 hours. The CDU requires a team of 140 registered nurses (RNs) and healthcare assistants (HCAs).
Originally, RNs and HCAs received separate handovers. The RNs received a handover on those patients for whom they would be caring from an RN on the previous shift. This took place at the nurses' desk. The HCAs undertook a walk-around, covering every patient in the unit, and received a handover from an HCA on the previous shift. This process had undoubtedly led to a divide within the CDU team and, as a result, there had been a noticeable breakdown in communication and some critical tasks for patient care had been missed. This impact could not be ignored.
Following many comments from the team to the author, it was decided that a positive change should be made to improve the nursing handover. It was hoped that this would encourage better communication within the team and ultimately lead to improved patient safety, which is of paramount importance.
First, all stakeholders were identified so that they would all feel involved in the change. Initially, the CDU matron was consulted on the proposed idea for change, and fully supported the need for a newly revised format of nursing handover. Following this, all bands of nursing staff (RNs and HCAs) were consulted via a questionnaire survey to see if this was a change they desired. The questionnaire comprised simple closed-answer questions, which gave respondents the option to expand on an answer in detail if they wished. This method and format was chosen in order to provide a mixed methodology of both quantitative and qualitative data. A handover champion team was also identified—this consisted of one member of staff from each nurse band. This was an important factor in the process for change as it was vital that the entire CDU team felt included and consulted in the decision to make the proposed changes. Their individual ideas were crucial in making this change possible. The handover champions helped to distribute and analyse the data collected from pre- and post-trial surveys.
Background research was undertaken into what information was available on how nursing handovers should be conducted. Unfortunately, there was a lack of practical information on what should be included, i.e. who should attend and where the handover should take place (Australian Commission on Safety and Quality in Health Care, 2010; West Midlands Quality Review Service and Society for Acute Medicine, 2011; Royal College of Physicians, 2011; NHS England, 2015).
The Royal College of Nursing's (RCN) Principles of Nursing Practice (principle G) states:
‘Nurses and nursing staff work closely with their own team and with other professionals, making sure patients' care and treatment is co-ordinated, is of a high standard and has the best possible outcome.’
Taking into account the lack of specific information discovered during the background research, it was evident that the CDU would have to develop its own specific requirements for a handover. The Quality Improvement Clinic's good practice checklist (Davey and Cole, 2015) was used as a reference guide to see what areas of the current handover process required improvement (Table 1).
| What do we need? | What does it mean? | Pre-trial: do we have it? | Post-trial: do we have it? |
|---|---|---|---|
| Leadership | There is a nominated leader for each transfer of care/handover | Yes. Nurse in charge of every shift identified | Yes. Nurse in charge of every shift identified |
| Values | Transfers and handovers are valued as an essential part of care and preparation for handover is a priority | No. We felt that some staff did not appreciate the importance of effective communication to patient care | Yes. The team now has more knowledge about why handover is important |
| Right people | The appropriate people are involved | No. Separate between registered nurses (RNs) and healthcare assistants (HCAs) | Yes. The whole team now attends (RNs and HCAs) |
| Specified time and place | A specific setting or place has been agreed where transfers of care can take place without interruption or distraction | No. RNs had their handover at the nurses' desk and HCAs did a walk-around | Yes. All RNs and HCAs have a verbal handover at the nurses' desk and then walk-around to visualise patients |
| Standardised process | There is an agreed process for transfers of care. This includes an agreed set of information to be covered in transfers (minimum data set). This is communicated in a structured way, is action focused, assigns responsibility for actions and is supported by clear documentation | No. RNs and HCAs given different information | Yes. All nursing staff are given the same information and jobs are allocated during the verbal handover. Could be improved |
Checklist framework from Davey and Cole/Quality Improvement Clinic, 2015
The results of the questionnaire revealed that 87% of the team felt it was time for a change to be made within the CDU, allowing all RNs and HCAs to receive handovers together. In addition, 97% of the current staff believed that this change would also help improve patient safety. The information gathered from the team was collated and underwent the Plan, Do Study, Act (PDSA) methodology with the purpose of implementing a 9-week trial (NHS Improvement, 2018). The PDSA method allowed assessment of the trial, enabling learning and development to take place from each cycle. Subsequently, this led to the team being able to make an effective change in a short amount of time.
The first trial consisted of pairs of one registered nurse and one HCA being allocated between 4 and 8 patients, and receiving a handover from an RN from the previous shift.
During the trial, a handover box was provided, which allowed the team to give anonymous feedback. This revealed that the team did not feel that the trial changes were benefiting the unit. Taking this into account, an alternative handover method was identified, which would support an integrated team approach. In their feedback, members of the CDU team stressed the importance of all bands of staff in each area being able to listen to the handovers for all patients. There was initial concern that this method would be too time consuming, but given that this was the suggestion most frequently mentioned in the feedback, it was agreed that this would be trialled. A 9-week trial of this handover method was conducted.
In the initial pre-trial survey, the team was asked where the nursing handover should take place; 54% stated that having a verbal handover at the nursing desk, with access to the patient notes and to the online observation system, was the most efficient and effective solution, partnered with completing a walk-around of the patients so that staff could introduce themselves. This would enable the staff to identify individual patients and gain a quick understanding of their individual needs.
Although some studies have stated the effectiveness of only doing a walk-around handover (Ballantyne, 2017) the CDU unit research team understand the importance of listening to and engaging with all staff in order to implement positive and successful change.
The CDU team was presented with a post-trial survey after 9 weeks of undergoing the trial. This was to gather information on whether the team thought the change had improved the handover process. Another questionnaire was distributed and 80% stated that they preferred the new method, with 83% believing that it improved patient safety. Further to this, the data derived from the HCAs was overwhelmingly positive. Before the trial only 23% stated that they knew enough about their patients after handover, compared with 75% in the post-trial survey. Before the implemented change, the HCAs felt that they only needed to be aware of a patient's mobility and continence status, whereas after receiving a more comprehensive handover, and some education on patients' acute medical conditions, they were empowered to take a more holistic approach to their care. This highlights the importance of continuous learning and development for successful patient care.
The information collated from the qualitative data provided great insight as it emphasised that the senior nurses on the unit felt that they were able to support the junior nurses more effectively through knowing about all of the patients on the unit. This engagement has made newly qualified staff feel more supported and may aid retention.
One unexpected improvement during this trial period was experienced by the patient-flow coordinators. Before the trial, the coordinators (band-3 health professionals) would not receive a full handover until 11 am, whereas during the trial they were updated by 9 am. This allows patients on the unit to be allocated beds on the wards at a faster rate, improving patient flow and helping to avoid accident and emergency department breach times.
Post-trial, the handover was once again compared with the Quality Improvement Clinic's good practice checklist (Davey and Cole, 2015). Table 1 illustrates how this change improved the nursing handover.
This handover method has now been implemented in the CDU. Overall, this change has enabled the CDU team to improve communication and patient care, which is a major success on its own. However, the key achievement of the change has been staff engagement, which has helped to remove unnecessary barriers between staff and increased their interest in what is happening on the unit. The whole CDU team became the main driver of the change and were empowered by knowing that their ideas alone could make a noticeable difference. The CDU research team was in constant communication with higher level management throughout the trial to ensure they were motivated and open to change. The research team plans to use this method to implement further quality improvement projects in the future.