Review
How to improve change of shift handovers and collaborative grounding and what role does the electronic patient record system play? Results of a systematic literature review

https://doi.org/10.1016/j.ijmedinf.2013.03.004Get rights and content

Highlights

  • Description of increased scientific interest in nursing and physicians handovers.

  • Handover tools integrated into EPR systems provide more and better information.

  • Only very few studies address collaborative grounding.

  • Different types of information will be needed for a collaborative grounding.

  • These types of information are usually not contained in electronic record systems.

Abstract

Introduction

Establishing continuity of care in handovers at changes of shift is a challenging endeavor that is jeopardized by time pressure and errors typically occurring during synchronous communication. Only if the outgoing and incoming persons manage to collaboratively build a common ground for the next steps of care is it possible to ensure a proper continuation. Electronic systems, in particular electronic patient record systems, are powerful providers of information but their actual use might threaten achieving a common understanding of the patient if they force clinicians to work asynchronously. In order to gain a deeper understanding of communication failures and how to overcome them, we performed a systematic review of the literature, aiming to answer the following four research questions: (1a) What are typical errors and (1b) their consequences in handovers? (2) How can they be overcome by conventional strategies and instruments? (3) electronic systems? (4) Are there any instruments to support collaborative grounding?

Methods

We searched the databases MEDLINE, CINAHL, and COCHRANE for articles on handovers in general and in combination with the terms electronic record systems and grounding that covered the time period of January 2000 to May 2012.

Results

The search led to 519 articles of which 60 were then finally included into the review. We found a sharp increase in the number of relevant studies starting with 2008. As could be documented by 20 studies that addressed communication errors, omission of detailed patient information including anticipatory guidance during handovers was the greatest problem. This deficiency could be partly overcome by structuring and systematizing the information, e.g. according to Situation, Background, Assessment and Recommendation schema (SBAR), and by employing electronic tools integrated in electronic records systems as 23 studies on conventional and 22 articles on electronic systems showed. Despite the increase in quantity and quality of the information achieved, it also became clear that there was still the unsolved problem of anticipatory guidance and presenting “the full story” of the patient. Only a small number of studies actually addressed how to establish common ground with the help of electronic tools.

Discussion

The increase in studies manifests the rise of great interest in the handover scenario. Electronic patient record systems proved to be excellent information feeders to handover tools, but their role in collaborative grounding is unclear. Concepts of how to move to joint information processing and IT-enabled social interaction have to be implemented and tested.

Introduction

Today, patient care in modern healthcare institutions is very much shaped by a condensed workload in a highly dynamic working environment in which health professionals focus on their specialized field. Continuity of care can only be achieved by the continuous, well-coordinated interaction of the different health professionals within and across shifts. Change of shifts does not compromise continuity from an organizational point of view as long as the actors who take over from their colleagues entirely replace their function [1]. However, continuity may only be ensured if the actors work in a coordinated manner and cooperate across shifts [2]. Due to their asynchronous nature, shifts obstruct an interactive exchange on demand between the different shift teams. Therefore, shifts possess a high risk for jeopardizing continuous coverage [3]. In order to partly overcome this dilemma, information has to be communicated at the shift change in handovers,1 in a consistent manner [4]. Handovers are, therefore, communication scenarios that are often ritualized [e.g. 5]. They are very similar across countries with regard to their content and structure [e.g. 6]. Very often they take place verbally in face-to-face situations [e.g. 7].

Cooperation enabled by handovers requires agreements on how to proceed and should lead to a joint understanding of the care process. This understanding is possible due to a shared knowledge background, which is defined by Clark as “the sum of the partners’ mutual, common or joint knowledge, beliefs and suppositions” [8]. Having such knowledge means that all actors know about a proposition, e.g. a fact about a patient, and at the same time also know that the others know it as well [8]. In order to achieve this level of comprehensive and effective understanding, mutual efforts among all the participants are needed, for which Clark coined the term “grounding” [9]. Hertzum refined this concept speaking of collaborative information seeking that consisted of information seeking, a primarily individual effort, as well as of collaborative grounding, which summarizes the joint efforts. The role of collaborative information seeking hereby was to balance individual and shared understanding [10].

In the context of handovers this highly interactive process of information and knowledge synchronization via questions and answers was called dance of reports [11], which lays the ground for detecting information needs [12] and proper decision-making [13]. The process of grounding also leads to awareness among all stakeholders. According to Kuziemsky and Varpio collaborative care delivery builds on awareness at various levels, namely patient status and goal awareness, team member awareness, deliberation awareness and rationale awareness, and finally environment awareness [14].

Grounding may utilize different communication mechanisms, which vary on a continuum between synchronous, e.g. face-to-face or phone communication, and asynchronous forms of communication. The method of choice for establishing common ground is synchronous communication – preferably in face-to-face situations – because it decreases the costs of establishing common ground [9]. It is also the method preferred by health professionals [e.g. 15]. However, synchronous communication was found to be prone to interruptions that may lead to treatment errors [16], [17]. In order to avoid these drawbacks, one could in principle rely on asynchronous communication methods. The effects are less positive than they may seem. It could be demonstrated that building shared knowledge on the goals and activities of patient care could not be supported by asynchronous means, such as a computer based order entry system [18].

Based on these studies, it remains unclear as to what is the most appropriate approach to effectively support the grounding process in typical synchronous scenarios such as handovers. Existing literature reviews which explored – among others – the current use of electronic handover systems provided only a first insight into the topic due to a lack of proper previous studies [4], [6], [19]. However, they

  • demonstrated the importance of handovers,

  • showed that handovers are error prone,

  • yielded an overview of the problems and barriers including the omission of important information, e.g. rationale of decision, anticipated problems,

  • listed strategies including structuring the information according to certain schemata.

By providing an exploratory overview they triggered the need for a new comprehensive and detailed review. This need holds true in general but specifically for integrated electronic systems supporting the communication and grounding process in handovers and their evaluation.

Against this background, the aim of this study is to answer the following research questions:

  • (1)

    Given the fact that collaborative grounding is prone to errors in synchronous communication scenarios, (1a) what are the specific types of errors and gaps in handovers performed by nurses and physicians? (1b) What are their consequences?

  • (2)

    What strategies and instruments for systematizing information and communication in handovers are described in the literature and how are they evaluated?

  • (3)

    What type are the electronic handover instruments that are reported in the literature and what is the role of electronic patient record systems?

  • (4)

    Are any of the strategies and instruments specifically addressing the grounding process?

The combination of answers provided by the literature to these four questions should help identifying the appropriate strategies for building an electronic handover system that helps overcoming the problems of the current practice.

Section snippets

Identification of studies

In order to answer these questions, a systematic literature review was performed in the period from May 2011 to May 2012 searching the MEDLINE, CINAHL, and COCHRANE. MEDLINE was accessed via PubMed.

We employed a similar procedure for identifying and evaluating the studies as Uslu and Stausberg [20] chose for a review on the added value of electronic patient records. The entire process is depicted in Fig. 1.

In a first step, we searched for titles and abstracts of the database entries for the

Statistics

Out of the 60 relevant articles, 25 were published in medical, 11 in nursing, 11 in quality management, 9 in medical informatics and 3 in healthcare journals, and 1 paper in a social sciences journal. Nine papers appeared in the years between 2000 and 2007, 51 papers since the beginning of 2008 (Fig. 2). More than half of the publications originated from the US (31), 11 from the UK, 8 from Australia, 3 from Canada and the remaining 7 from other European countries.

All studies were conducted in

Summary

The increasing numbers of publications on intra-institutional information transfer since 2008 reflect the growing awareness about the importance of, and interest in, handovers in recent years. This interest was probably triggered by national initiatives foremost the initiative “Safe Handover: Safe Patient” of the British Medical Association from 2004 [82], which was followed by an initiative in Australia three years later [83]. In the year 2006 “effective handoffs” became part of a list of

Limitations

This literature review concerns a particular clinical communication scenario, namely handovers. Some of the studies made clear that handovers and ward rounds have much in common and depend on each other. We did not go into the details of this interaction but rather focused on the handover scenario as an example of a highly demanding instance of clinical communication to ensure continuity of care. How to possibly exploit these results for other communication scenarios has to be analyzed in a

Conclusion

This review gives insight into the high priority topics currently investigated by handover studies and those topics not yet or scarcely discussed. While we know much about communication failures, how to avoid them in terms of better structures and how to make use of electronic patient records and related handover tools to improve information quality and quantity, little is known still about the more advanced employment of IT in pre-handover, handover and post-handover situations. Grounding as

Author contributions

Both authors qualify for authorship by their substantial contributions to the research and production of the manuscript. DF and UH provided substantial input in the conception and design of the review. DF collected the majority of the studies and UH contributed. DF drafted the manuscript and UH critically revised it and provided the final version of the manuscript.

Competing interest

All of the authors declare that they have no conflicts of interest, financial or otherwise, to disclose.

Summary points

What was already known on the topic?

  • Handovers at changes of shift are a central, but error prone, node in the care continuum.

  • Structured instruments have a great potential of improving the quantity and quality of information transmitted at changes of shifts.

What this study added to our knowledge?

  • The scientific interest in nursing handovers and physician sign-outs has increased

Acknowledgements

This work was funded by the European Regional Development Fund (ERDF) and the Federal State Lower Saxony, Germany.

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