The handover is described as the process where an individual is given the authority be in control over something (Brutonet al., 2016). The clinical handover is described as the process of advanced communication and is required for the purpose of ensuring the safety of the patient (Donnelly et al., 2018). Good communication is required in this area due to the complexity in order to improve the care and safety of patients. The process of clinical handover is an important area of concern in the management of patient care (Zakrisonet al., 2016). The safe handover is considered as a complex process, yet it can provide assistance to different healthcare professionals to achieve effective outcomes for the patients (Clarke, Clark-burg and Pavlos, 2018). Due to the changes in the medical workforce patterns, the clinical handover is considered as an imperative practice. For ensuring the safe clinical handover, the medical professionals, health administrator, and nurses are required to work in collaboration (Velev, Bachmann and Ikeda 2018).
The predefined focus of this paper is to provide narrative and critical literature review of mental health nursing handovers for the evaluation of the effectiveness of using the structured handover tools for improving the process of communication among nurses (Forde et al., 2018). The primary studies for the narrative review has been selected from different database and the critical appraisal presents the summary of the outcomes (Kerr, Lu and McKinlay, 2013). According to the code of conduct presented by the Nursing & Midwifery Council (NMC2015), the confidentiality and privacy of the patients are maintained to meet the ethical consideration. In addition, this paper carried out systematic review honestly so as to follow the ethical guidelines provided by the university.
Problem, Context and Background Literature
To ensure the safety of the patient, the clinical handover is considered as a prime factor in the nursing field and to ensure the patient’s safety, safe clinical handover is imperative (Kerr, Lu, and McKinlay, 2014). The process of clinical handover is complex, which is comprised of handing over of information by one nurse to the other and communication must be of a high standard for maintaining the safety of a patient.
As revealed by the research studies, the effectiveness of the handover process is affected by different aspects and one of these factors includes the management of time and effective communication (Khuan and Juni 2017). The chances of errors and near miss increase during handover if appropriate process is not followed. Different research studies have highlighted the negatives consequences associated with the verbal handover and other forms of the unstructured handover (Malfaitet al., 2018). One of the prime risks is the loss of important information about the patient, which can affect the process of care negatively. In this regard, the safe clinical handover by using the handover tool is considered as appropriate as it can ensure the safety of the patient(McMurray et al., 2011). There are different tools, which are developed for the safe handover of the information. In this context, the handover tool is the standardised tool, which is used for the transfer of information in a structured manner.
The World Health Organisation (WHO, 2007) and the National Institute for Health and Care Excellence (NICE, 2017) have recommended the use of handover tools for effective communication and ensure patient safety. However, (NICE, 2017) has presented the time as the major constraints, and revealed the selection of the most effective tool based on the needs of the patients. Among different handover tools used for effective communication, the tool, which is recommended by WHO is “Situation, Background, Assessment and Recommendation” (SBAR tool) (Shahid and Thomas 2018). This tool is effective for the structured handover and can be implemented in different healthcare settings. In addition, another tool, which is used for the structured handover is “identify-situation-observations-background-agreed plan-read back” (ISOBAR) and is comprised of a checklist for effective communication (Ramasubbuet al., 2016). Thus, the use of structured tools for handovers vary from one healthcare setting to the other and the main question, which arises in this situation is that whether the structured handover can improve the communication among nurses to ensure the safety of the patient (Spinkset al.,2015).
Different research studies have demonstrated the significance of structured handover tools and use of systematic tool would assist to explore the benefits of the structured tools (Achrekaret al., 2016). Yet, there is limited research about the effectiveness of the structured handover tools in the mental health nursing field (Slade et al., 2018). This is the reason that there is a need for further research studies, which can demonstrate the significance handover tools in the mental health nursing practice.
Search Strategy and Keywords
For the selection of the primary studies for this review, different data base were used and these data base included the PsychINFO, CINAHL, MEDLINE and Science Direct. For the purpose of selecting the most relevant information, the Boolean operators “AND” and “OR” were used for searching. Different keywords, which were included in this research were handover, handover tool, nursing, patient, communication, structured, unstructured, SBAR, psychiatric (Qin et al., 2016).
For developing the searchable, PICO was used for breaking the question. The PICO is an extensively used evidence-based practice framework to achieve the answer of the question. PICO stands for population, interest and context. The question is
“What is the effectiveness of using the structured handover tools for improving the process of communication among nurses?”
|P||Population||Mental health nurses|
|Co||Context||Mental health patient|
The inclusion and exclusion criteria were also designed and the inclusion criteria include the research studies, which were published from 2010-2018 so as to access the latest information and the research studies published in English language. In addition, for this review, the peer-reviewed articles from academics journals demonstrating the significance of handover tools in mental health practice were included. On the other hand, the exclusion criteria for this research were the research studies published before 2010, the studies published in a language other than English and the studies, which were not focusing on the mental health environment.
This research study is based on the narrative literature review, and this is described as the literature review and is carried out without the use of rigorous method for search. For this narrative review, the systematic strategy is used for research; however, rigour standard of narrative review is low then the systematic review. However, to ensure the reliability and relevance of the literature, recent research studies were used. Further, the reference list of different research studies was also reviewed so as to select further research articles, which meet the inclusion criteria of the research.
|100 papers were identified by using databases|
|77 papers were excluded due to duplication|
|77 papers were screened using inclusion criteria|
|50 were excluded|
|20 studies were excluded|
|27 were assessed for eligibility|
|7 studies were selected for the review.|
Data extraction is a key step in synthezing literature hence literatures were critically evaluated by taking into consideration the area of study, aims and objectives of the study, the sampling and sample population as well as the findings of the research. The data extraction table is presented in the appendix.
Description of Studies
The qualitative as well as quantitative studies were selected for this review. All of these research studies were based on the standardised methods and published in the renowned journals. Some research studies were also based on the use of both qualitative and quantitative approaches for the collection of information. Waters et al (2015) was based on both qualitative and quantitative research design. Abela-Dimech and Vusik’s (2018), research was based on the survey and the plan-do-study-act framework. The research study carried out by Hunt et al (2012), was based on the cross-sectional research design. Research carried out by Milar et al., (2015) was based on the use of both quantitative and qualitative approach. Farrara et al., (2017) carried out a research by using the evaluation scale and 10 nurses from different units were selected and information about the tool was provided to these nurses and the outcomes was quantified by using the numbered graph scale. Plunkett (2015) presented the cross sectional research based on an evaluation of handover in improving communication in mental health units. The research by Poh et al. (2013) was based on three phases over a time period of 4 months and four admitting wards were considered for this research. These research studies took the ethical principles and guidelines into consideration.
For the critical review and appraisal of the research articles, six questions presenting the checklist for the critical appraisal were used. Different themes were identified from the research questions and information was aligned in these themes. The prime theme, which has been identified from the literature, was the prime issue of conveying of unnecessary information during the process of handover. As demonstrated by different healthcare providers associated with the process of handover, some irrelevant and unnecessary information is conveyed.
Unnecessary or Duplicate information conveyed during Handover
The first theme identified was the unnecessary or duplicate information conveyed during handover. This issue was apparent throughout the literature, with staff expressing that some of the content discussed was unnecessary or missing critical details. To demonstrate the importance of this problem, a research study was carried out by Water et al (2015) and this was published a renowned journal “International Journal of Mental Health Nursing”. This research study was based on the demonstration of the effectiveness of handover observation tool. One part of the research was based on the use of the quantitative method and the data collected regarding the efficiency of this observation tool which was interpreted by the use of statistical analysis approach. The research has revealed that handover tool is associated with sharing of unnecessary information as well as there is lack of patient-centred data as the mental state was discussed in almost all cases, while preferences of the patients were only discussed in 53% cases.
The qualitative data were collected by the use of structured observations and the approach which was used for analysis wascontent analysistechnique and different reoccurring themes were identified from the data. As demonstrated by the data, the handover process is a continuous as well as the repetitive transfer of information and its lacks appropriate structure due to which, less information is conveyed. The present research is associated with some positive points, which have increased the reliability and validity of the research. An important point is that this research was carried out by a single researcher, which has decreased the chances of research bias. Furthermore, the researcher has used an observational tool for recording information by using a systematic approach. However, one limitations of this research was that this research was carried in the single healthcare unit on a sample size of 20 members.
In this regard, another research study carried out by Hunt et al (2012) and published in “Journal of Psychiatric and Mental Health Nursing” was based on the cross-sectional research design and this research study presented the approaches used for handover in the community setting in Australia. This research was based on two parts and the first part was the quantitative part, which was based on the survey from 1125 participants working as the health care professionals such as psychologists, social workers and the nurses. The questions in the survey were based on different questions regarding handover with some choices. Among these participants, 380 participants responded and half of them were nurses. As demonstrated by the outcomes, more than 70% of the participants communicated appropriately, yet the participants also mentioned the drawbacks of the process. Among these participants, 31% demonstrated the lack of training by the staff members to carry out the appropriate handover, while 25% of the participants mentioned that unnecessary information about the patient is the normal error during the handover process.
The second part of this research was based on qualitative research design and the views of external healthcare providers were taken to decrease the risks of bias. The outcomes of the qualitative part were similar to the first part of the research. The participants revealed that there is a risk of duplication or sharing of unnecessary information of the patient. The limitation of this research was carried out in a single healthcare setting and the sample size was not enough to provide generalised outcomes. Another limitation of this research was that the results cannot be considered enough as this research has considered different healthcare professionals; yet, the handover is mostly the responsibility of the nurses.
Another research study carried out by Abela-Dimech and Vusik (year). was published in the “Archives of Psychiatric Nursing”. The focus was to demonstrate the effectiveness of implementing SBAR for 27 inpatient psychiatric units and its effectiveness to ensure the safety of patients. This research was based on the survey and the plan-do-study-act framework was used for the adoption of this tool and after educating staff, the audit was carried out.The findings of this research revealed that SBAR implementation is increased due to effective communication and handover. The outcomes revealed that effective implementation of this handover tool can lead to positive safety outcomes.
The findings of this research were also relevant to the results of water et al., (2015) and patients’ safety was improved by effective implementation. Similar to the research of Hunt et al., (2012), the use of structured handover tool assists the healthcare providers to share only the specific information and patient. However, the limited communication of information has been presented as a serious issue associated with structured interviews by these three studies due to time constraints. For overcoming this issue, it is imperative that all the main points and critical information are shared.
The observational research carried out by Milar et al (2015) was published in the Journal of Psychiatric and Mental Health Nursing and it was based on the use of both quantitative and qualitative approach. The study was carried out in Australia and was related to the identification of the method used for information communication and information shared. Based on WHO 2017 principles, handover observation tool was observed in the first part and second was based on discussion. Considering quantitative outcomes, the risk of information loss was consistent. Yet, management of the patients who are considered at higher risks is discussed but their information is not discussed. Approximately 85.7% of patients, who were considered at low risks were only discussed and this can affect the health delivery process.
The discussion demonstrated that the nurses are concerned about the safety of the patient as they consider that consistent information is not communicated. In this regard, considering the risk factors is important to reduce the chances of negative consequences. However, the outcomes obtained from the discussion are also associated with some limitation such as low reliability. The sample size used for this study was also limited and the time taken to conduct this study was also limited. In addition, the number of participants involved in the discussion was not mentioned and therefore reliability of research is reduced.
Inconsistencies related to the Time for Handover
Another theme for this paper was the inconsistencies related to the time for handover and the impact of time limitations on communication. In this regard, Farrara et al., (2017) carried out a research, which was published in “the British Journal of Nursing” and assessed the handovers quality of mental health unit in comparison to a teaching hospital. The quality was assessed by using the evaluation scale and 10 nurses from different units were selected and information about the tool was provided to these nurses and the outcome was quantified by using the numbered graph scale. The outcomes mentioned that the night to morning handover revealed more inconsistencies as compared to the night –morning handover because of limited time. The outcomes recommended that time limitation, as well as fatigue at the end of shift can be associated with the inconsistent and unstructured handover. However, Abela-Dimech (2018) revealed that improvements are required in the handover process to decrease the waste of time due to irrelevant information.
The research carried by Farrara et al., (2017) was based on systematic methodology and outcomes cannot be generalised. A further limitation was that this research was carried out in Italy and at Italy; the mental healthcare units are different from the United Kingdom. The outcomes revealed that using structured handover can eradicate the risks of information inconsistencies. As identified by these research studies, the time constraints can impose a negative impact on handover and due to limited time, the compliance of the handover process is negatively affected. Further, there is no proper set time for handover and usually, handover takes more time than mentioned. Thus, the shorter handover can affect the compliance and quality of handover and thus demonstrated that fatigue and time limitation can affect the quality of handover.
Effects of the Structured Handover Tool on Patients’ Safety and Effective Communication
Another theme related to this research was the effects of the structured handover tool on patients’ safety and effective communication. In this regard, Plunkett (2015) presented the cross-sectional research, which was based on an evaluation of handover tool in improving communication in mental care units. This research was carried out in North American and the survey was used for the evaluation of the effectiveness of handover tool. The analysis of data provided the outcomes that 82% mentioned the need for changing the process of handover. After the implementation of handover tool, most of the participants revealed there is an increase effectiveness of communication and low interruption, yet 10% mentioned that information shared is not relevant. This research indicated that there are potential benefits associated with the implementation of a structured handover tool in mental health settings. However, the sample size was small and the response rate was also low.
Research carried out by Poh et al (2013) was published in the “international Journal of evidence-based healthcare” demonstrated the significance of effective and effective shift handover for the safety of the patient. The research was carried out in Singapore and revealed the benefits of current practices used for the handover. The research was based on three phases over a time period of 4 months and four admitting wards were considered for this research. The outcomes were derived for 212 cases and the findings obtained from audit mentioned that 49% improvement is achieved in compliance by using structured handover tool and considering the handover at the start of cases resulted in 74% improvements in compliance rate. This project concluded that use of effective handover can be associated with improved patients’ safety outcomes.
The narrative review of this research studies has revealed the prime aspects, which are important to ensure the effective and safe handover (Milar et al., 2015). Furthermore, the review has also revealed the significance of appropriate communication and effective handover tools are associated with benefits, while unstructured handover can lead to information loss, misinterpretation or ineffective communication (Abela-Dimech and Vusik 2018; Water et al., 2015).
The use of structured handover tools would be effective to improve communication and ensure the safety of patients. The handover, which was verbal and comprised of the limited time was related to poor communication and thus result in improper outcomes (Milaret al., 2015). As time limitation is a major element in mental health units, therefore, there is need of structured handover tool to save time and ensure appropriate communication. In this regards, the training of nurses is required. This is also demonstrated by NMC code of conduct (2015).
The narrative review of all the research studies mentioned that using a structured handover tool can ensure effective communication and safety of the patients. The comparison of the unstructured handover tool with the structured tool also present the results that using the structured handover tool is effective for making improvements in communication and ensure the delivery of effective information about the patient (Abela-Dimech and Vusik 2018; Water et al., 2015). The summary of findings also revealed that there is an extensive need of considering the communication of relevant information to overcome the time constraints.
There are few limitations for the present narrative review and one of this limitation is the lack of English studies due to which non-UK basedresearch studies are considered (Farrara et al ., 2017; Abela-Dimech 2018). Due to the use of research studies carried out outside the United Kingdom, it is difficult to generalise the outcomes as the healthcare system of the UK is different from other countries such as America and Australia. Furthermore, most of the research studies considered for this review had small sample size both the qualitative and quantitative research and therefore, there is low reliability (Plunkett 2015; Pohet al., 2013). However, all the research studies considered for this review followed the ethical standards.
The critical review of the effectiveness of the handover has revealed that communication in the mental healthcare settings can be improved with the use of structured handover tools. This research has considered only a few studiesderived from the international literature due to the lack of English studies. The findings of these research studies demonstrated that the use of structured handover will reduce the risks associated with the unstructured handover and can improve patients’ safety by resulting in effective communication. However, there is a need to carry out further evidence based research studies using a larger sample size and to get reliable outcomes.