How do handovers happen? A study of handover-at-shift changeovers in care homes for older people

February 2017

Caroline Norrie, Valerie Lipman, Jo Moriarty, Rekha Elaswarapu and Jill Manthorpe

Social Care Workforce Research Unit

Disclaimer and acknowledgement

This views and opinions in this discussion paper are those of the authors and should not be interpreted as those of the funders of their research. We thank the care homes’ owners and managers who helped with this study and the care staff who took part in interviews and participated in observations. All those participating were given a certificate of participation in research.

We thank the SCWRU Service User and Carer Group for its consideration of this study. The study was funded by the Abbeyfield Research Foundation and we are most grateful to the Abbeyfield Society for its support. The views expressed in this report are those of the authors alone.

Front-cover photo of care home courtesy of Oaklodge Nursing Home and the Irish labour Party.

About the Policy Institute at King’s

The Policy Institute at King’s College London acts as a hub, linking insightful research with rapid, relevant policy analysis to stimulate debate, inform and shape policy agendas. Building on King’s central London location at the heart of the global policy conversation, our vision is to enable the translation of academic research into policy and practice by facilitating engagement between academic, business and policy communities around current and future policy needs, both in the UK and globally. We combine the academic excellence of King’s with the connectedness of a think tank and the professionalism of a consultancy.

About the Social Care Workforce Research Unit

The Social Care Workforce Research Unit (SCWRU) at King’s College London is funded by the Department of Health Policy Research Programme and a range of other funders to undertake research on adult social care and its interfaces with housing and health sectors and complex challenges facing contemporary societies.

Contents

Executive summary ................................................................................ 4

Introduction ............................................................................................. 5Background .......................................................................... 5This study ............................................................................. 5

Observations and interviews in five care homes .............................. 8

The sample: five care homes .............................................................. 9Descriptions of handovers ................................................................ 11

Timing and duration ..............................................................11Who hands over to whom, and who participates? ............... 12Location ............................................................................... 14Content of handovers and artefacts used ........................... 15

Staff perceptions on the purpose and effectiveness of handovers ........................................................................................... 19

All staff: communication ensures continuity and safety – ‘It’s part of the job’ .......................................... 19Managers’ and nurses’ Perceptions: management, team-building and training ............................. 21Care assistants’ perceptions: resident safety and being prepared – ‘So it's not like going into the wilderness!’ ......... 22

Perceptions of all staff and the SCWRU Service User and Carer Group on key elements of effective handovers ........................... 23Summary of indicative elements of an effective handover from participants’ perspectives .............................................................. 25

Discussion ............................................................................................... 26

References ............................................................................................. 29

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This report presents the findings from our study into the content, purpose and effectiveness of the handover of information about older residents between care home staff coming off duty and those coming on duty. The study consisted of a literature review and qualitative research undertaken in five care homes using an ethnographic approach in which handovers were observed and interviews conducted with a range of staff. We found:

• Handovers varied a great deal across the five sites in terms of frequency, duration, location, content and who handed over to whom.

• In the five case-study locations, most participants viewed handovers as an intrinsic part of care home routines and as vital for ensuring good communication between staff and residents, and continuity of care and safety for residents.

• Care assistants said handovers helped them prepare for duty and take on responsibility for resident safety. Some managers and registered nurses considered handovers had additional uses as opportunities for team-building, ensuring members of staff were allocated appropriately, organising human resources generally, and staff training.

• Whatever model of handover adopted, staff believed that handovers were effective. They identified key elements of a successful handover as enabling staff to listen without too many distractions; being understandable and clear; providing an opportunity to ask questions; and respecting the confidentiality and dignity of residents.

• Not all of the staff involved in this study reported they were paid for the time they spent on handover. However, they viewed this extra time as integral to their responsibilities.

Executive summary

• Members of the Social Care Workforce Research Unit (SCWRU) Service User and Carer Group discussed this study from their perspectives and noted the importance for some family members of having readily available and accessible written documents to monitor the care of their family member or friend living in a care home.

• Dissemination of the findings is underway. An article summarising the literature view has been submitted for publication in an academic journal (Lipman et al., 2017). Another article will be produced drawing on the observations. Emerging findings were presented at a National Care Homes Research and Development (NCHR&D) Forum event (Norrie et al., 2016) and discussed with other care home researchers. A summary of overall findings, including key elements of what were considered successful handovers, will be sent to the participating care homes.

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Introduction

This report presents the findings from our study into the content, purpose and effectiveness of the handover of information about older residents between care home staff coming off duty and those coming on duty. The study consisted of a literature review and qualitative research undertaken in five care homes. We took an ethnographic approach in which handovers were observed and interviews conducted with a range of staff.

Background

The generic term ‘care home’ is used in England to refer to long-term care facilities which are divided into those ‘with’ or ‘without’ nursing care (Orellana et al., 2016). Care homes ‘with nursing’ (often referred to as nursing homes) are required by law to have a registered nurse on duty at all times, whereas homes ‘without nursing’ (sometimes referred to as residential homes) are not. In 2014, the Care Quality Commission (CQC) reported that there were 17,350 care homes registered in England. Of this number, 4,676 were care homes with nursing and 12,976 were care homes ‘without nursing’. These totals include a small number which have dual registration (CQC, 2014a). One study estimated about six out of 10 older people live in care homes with no on-site nurses (Szczepura et al., 2011) where their access to nursing care is via community nurses. Nursing homes generally have a larger number of residents than residential homes. Care homes are commonly registered to provide care and accommodation for more than one group of people, but of the 17,350 registered care homes in England, two-thirds (64%) are registered for older people (CQC, 2014a).

The English care home market is characterised by several different types of owners, including small family businesses, voluntary sector or not-for-profit operators, and large national and multinational chains with homes in many different locations, some of which are venture capital-funded organisations (see Burns et al. 2016). Handover practices and cultures in care homes may therefore

be shaped by differences in employers, business models and philosophies of care.

Residents move to care homes late in life and are often frail (Lievesley et al., 2011). Since the financial crisis of 2008, additional funding restrictions have been introduced in publicly funded social care, with implications for care-home organisation, staffing levels, workload intensities, skill-mix and staff ability to provide quality care (Burns et al., 2016). This is in a sector already known to have poor levels of pay (despite the introduction of the National Living Wage), limited opportunities for career advancement, and where recruitment and retention are major problems for many providers (Wild and Kydd, 2016; Cavendish, 2013). Approximately half (49%) of residents living in care homes with nursing are publicly funded through local authorities, and the NHS and many care homes are experiencing financial difficulties (Laing and Buisson, 2014). At the same time, the introduction of the National Living Wage of £7.20 per hour for those aged 25 and over in April 2016 has increased labour costs for care homes (Wild and Kydd, 2016), although these may be recouped if it encourages staff retention. The most recent evaluation by the CQC (2015) in England rated just over a third (36%) of residential homes and just over half (55%) of nursing homes as inadequate or requiring improvement. In a study of 12 care homes, Burns et al. (2016) reported that one home had stopped handovers that included all the staff and, in another, payment for attendance at handovers had been withdrawn as a reported consequence of financial pressures.

This study

The initial phase of this study was a literature review which confirmed that handovers have been studied in the main in hospitals, within and between clinical areas, between different professions (eg doctors and nurses) and involving transfers between locations (eg hospitals or discharge settings) (Cohen and Hilligoss, 2010).

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In contrast, there is little research evidence about handovers in care homes for older people (Lipman et al., 2017; Szczepura et al., 2008). The extensive literature on handovers from nursing highlights that they are a well-established part of practice in clinical settings (Riesenberg et al., 2010), but the extent to which these practices are transferred or replicated in care homes ‘with’ and ‘without’ nursing has not been addressed.

When referring to clinical practices, the terms ‘handover’ and ‘report’ are frequently used in England, but internationally, ‘handoffs’, ‘shift reports’ and ‘shift-to-shift reports’ are also common (Patterson and Wears, 2008). Poor handovers are well evidenced in health services as contributing to medication and diagnostic errors, accidents, delays, poor safety and poor patient satisfaction (Riesenberg et al., 2010). This is also tentatively reflected in the small amount of care home literature; Tariq et al. (2015), for example, scrutinised records in three residential homes in Sydney, Australia, and found that poor handovers contributed to prescribing errors.

Using staff focus groups, Wheeler and Oyebode (2010) asked staff about quality and effectiveness of communications about people with dementia in nine nursing and residential homes in the West Midlands of England. They heard that handovers typically took place three times a day, were brief, relaying only pertinent information from the previous shift. In three homes, handovers only involved the senior care workers on duty. Some homes had separate handovers for nurses and care assistants; such ‘demarcation’ was seen as a potential source of conflict. With the exception of this study (and template forms authored by Berkshire Council (Haines and Davey, 2011)), we found little material relating to either the content, practices or the outcome of handovers in care homes in England.

Surprisingly, despite the potential centrality of handover in the activities of care homes, the CQC guidance for providers does not offer specific guidelines on what constitutes good practice in care homes, although handovers are referenced 14 times as part of the Key Lines of Enquiry (KLOEs) (CQC, 2014b). The CQC notes that handovers are an important tool for assessing various matters, such as safety, effective communication, working together and person-centred routines.

Areas of interest raised in our literature review stemmed from clinical health settings that may affect care homes; these included: debates about

whether handovers are more effective if carried out face-to face, using the telephone, via written notes, or IT (Frankel et al., 2012); what is best practice in terms of location for handovers – for example, at the bedside or staff room, at a computer or at a black/white board (Anderson et al., 2015); and the merits of standardised models or guidelines such as the medical Situation-Background-Assessment-Recommendation (SBAR) (Cohen and Hilligoss, 2010) or nursing Head-to-Toe (H-T-T) (Popovich, 2011). Meanwhile, qualitative studies have noted the less explicit potential functions of handovers, such as team-building, coaching, education and support (Anderson et al., 2015).

One area where a small group of studies about handovers in care homes is emerging is the introduction of point-of-care electronic systems, especially in Australia (Zhang et al., 2012; Gaskin et al., 2012; Munyisia et al., 2011). These studies have particularly focused on the evaluation of electronic handover systems (Lipman et al., 2017). Lyhne et al. (2012), for example, examined hybrid/paper/electronic systems in a large nursing home and highlighted the duplication of information, lack of standardisation, guidelines, protocols and information sources in non-electronic systems, commenting that in this context electronic systems may have potential.

Running in parallel to the academic literature, media accounts also report developments in care homes, such as the use of handheld electronic devices to document information needing to be recorded for handovers. A recent article in The Guardian (Hardy, 2016) describes a pilot experiment in one care home where handover notes were recorded electronically using a mobile application (with automatic prompts for staff to follow up actions depending on their inputs, and which automatically updates care plans). A report is then made available to relatives based on

Photo: Care Quality Commission

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nutrition, activities and hydration. Plans to develop this technology include adding sections on hygiene, medicine, sleep and life history. These categories point to the content of handovers in this care home but little is known about the cost-effectiveness of this practice and the reality of implementation.

Efforts to reform policy and law that could have implications for handovers have also been reported in the media. For example, a relatives’ group has started campaigning for the introduction of a ‘Robin’s law’ (named after Robin Kitt Callender) to make it a criminal offence for a care home not to inform next of kin if someone they support, who lacks capacity, has an ongoing illness resulting in death (Salman, 2016). Should this legislation be introduced, the handover process might need to adapt accordingly by emphasising and recording in greater detail interactions with relatives.

This brief summary of our literature review highlights the lack of information about handovers in care homes, especially staff views on their content, purpose or what they think is effective. It is therefore these particular areas that the observational element of this study was intended to address.

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Observations and interviews in five care homes

Aims

We were interested in investigating the content, purpose and effectiveness of the handover of information between two different sets of care home staff – those leaving a shift and those arriving to start a shift. For example: how changes in individual residents’ needs, wishes and circumstances are communicated between shifts; the dynamics between the staff giving and receiving handover information; and what are considered by staff and stakeholders as key elements of an ‘effective’ handover in a care home.

Methods

An exploratory, micro-ethnographic, qualitative approach was used to study the handover process at shift changeovers between two groups of staff – those going off duty and those coming on duty. This approach was chosen as handovers were conceptualised as social interactions and influenced by organisational cultures (Luff et al., 2011). Organisational culture may be described as the way in which things are done, or a particular way of behaving in a given work setting, the way of life of a workgroup – whether this is in a specific setting such as a hospital ward or care home – or else a wider field, such as types of care homes. Adopting such a perspective means that handovers can be seen as rituals in organisational settings, with participants sharing tacit unspoken knowledge. Holloway and Todres (2010) referred to ethnographers examining such tacit knowledge with the purpose of making it explicit, and this approach guided our data collection and analysis.

A purposive sample of care homes was recruited to ensure a variety (eg privately owned, voluntary/not-for-profit, member of a chain) were included in this study. A sample matrix of 20 potential participant care homes was constructed after identifying homes through researcher contacts and internet searches (including CQC information). Managers/owners of selected homes representing

different types of facility were then invited to take part in order to achieve our target of five care homes.

The fieldwork team consisted of three researchers who collected data in one care home each (CH1, CH2, CH5) and another researcher who undertook data collection in two sites (CH3 and CH4). This approach meant the experiences of all the team informed the project but the care homes did not have the disruption of multiple visitors. In each care home we ensured a selection of staff were interviewed, including owners/senior management staff, registered nurses (where present) senior/general care assistants and staff working day and night shifts in order to gain a cross section of views and experiences.

Interviews were recorded (with consent), fully transcribed, and entered into NVivo qualitative analysis software package, along with observational field notes. Notes were written up as soon as practically possible after the visit, differentiating direct observations from interpretations using an approach based on Spradley’s work (1980). These combined data were analysed using a matrix analysis approach to compare pre-existing categories related to the research questions and to emerging themes, relating to both processes and meanings (Miles and Huberman, 1994).

The study was supported by the Social Care Workforce Research Unit (SCWRU) Service User and Carer Advisory Group, which consists of 15 members and brings a range of experiences, including supporting family members living in care homes and being lay inspectors of care facilities. The research plan for the study was presented to the Advisory Group and their views on effective handovers were noted. These were analysed together with other data. In preparation for our fieldwork in the homes we also interviewed a key informant (Stakeholder 1), a senior care assistant with research experience, to collect their ‘insider’ views on what we should observe and record in our study.

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Ethical permissions

This study received approval from the King’s College London Ethics Committee. We ensured the study was conducted in an ethical manner throughout. Care home managers who agreed to participate in the study informed their staff about what was involved via emails and posters. Staff were given the opportunity to opt out of participating in observations and to volunteer to take part in interviews. During observations, no notes were taken about residents that could identify them. Staff who volunteered for interviews were given an information sheet detailing the study and also their right to withdraw at any time. Written consent was obtained for recording the interviews, which were transcribed for analysis. A confidentiality agreement is in place with the transcribing organisation, and all data were treated as strictly confidential and stored following data protection regulations.

The following descriptions briefly outline the five case-study care homes and their approaches to handovers. It should be noted that all the care homes were in the South East of England and recruitment and retention of staff were a continual challenge in four of the five locations. In all homes, the staff consisted of workers from a variety of mainland European and international locations. The term ‘care assistant’ is used throughout, although some locations used the term ‘healthcare assistant’ and ‘care co-ordinator’, and sometimes staff referred to care assistants as ‘carers’.

The sample: five care homes

Care Home 1 – Private family-run, for-profit care home – with nursing

CH1 is a registered care home for people requiring nursing or personal care with nursing that has capacity for 50 residents. CH1 uses a mostly paper-based handover system. The CQC overall rating for CH1 is ‘Good’; it was last inspected in 2015.

Care Home 2 – Small, for-profit, private chain (of three) care home – with nursing

This is a registered nursing home for people requiring nursing or personal care with nursing that has capacity for 50 residents. It is part of a small group of care homes. CH2 uses a mostly paper-based handover system although staff

‘clock in’ using an electronic system. The CQC recently rated the home as ‘Good’ (2016), although the ‘responsive’ domain was graded ‘requires improvement’. The CQC report included two specific references to handovers: first, their midday timing could delay supporting residents with eating; and second, handovers were thorough but lacked information relating to psychological wellbeing.

Care Home 3 – Small, not-for profit care home – without nursing

CH 3 is a small care home run by a voluntary/not-for-profit organisation. It provides accommodation for 26 older people but not nursing care. CH3 uses a hybrid documentation system, where care plans are electronic, but other notes are on paper. The home was inspected in 2015 by the CQC and rated overall as ‘Good’, although on the ‘safe’ domain the judgement was that it required some improvements.

Care Home 4 – Large for-profit chain – with nursing

CH4 is a large 150-bed home offering residential, nursing, respite and dementia care and is part of a large national chain. Each unit or wing has a specific registered nurse as well as a unit manager who leads on the shift handover process. One wing is for residents from an Asian background. In CH4, a hybrid documentation system is in place: care plans are electronic, but other notes are on paper. A CQC inspection was underway at the time of our study.

Care Home 5 – For Profit Care Home – without Nursing

CH5 is a registered care home for older people who require care but not nursing, although palliative care is provided. There are 22 residents. It is owned and run by the General Manager, who also owns another home in the area. The CQC overall rating is 'Good'. This care home is unusual compared to the other four homes as there are three shifts per day: 7am-2.30pm, 1pm-9.30pm, and night (7.30pm-7am). In CH5, an electronic system is in place and members of staff use an application on their mobile phone to update daily handover notes at the point of care.

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Table 1: Summary of handover practices (RN = registered nurse; CA = care assistant)

 

Timing Who hands over to whom Location Processes

Content

Systematic reporting on each resident?

Items commented on?

CH1

Privately owned, family run (residents = 50)

8am (always)

9am (sometimes)

2pm (sometimes)

8pm (always)

RN to RN; RN to CA

Nurses to CAs after breakfast.

Handover to CA coming on.

CAs to RN; then RN to RN

Nurses station/or walk around room by room

(If room by room, CAs listen outside the door – no need for 9am handover)

Mostly paper Systematic discussion of each resident – notes made by incoming nurse/senior care workers, keys passed over

CH 2

Small chain (residents = 60)

8am (always)

12 midday (sometimes)

8pm (always)

Night RN to all staff (RNs and CAs)

Day RN to all staff at 12am

CAs to RN throughout day and at end of shift. Day RN hands over to all staff (RNs and CAs)

Nurses’ station/staff room, or lounges if confidentiality needed

Mostly paper Systematic discussion of each resident following printed sheet with names and inputs/ outputs

CH 3

Non-profit/voluntary sector (residents = 26)

7.45am (always)

7.50pm (always)

All staff (day and night shift) and the Manager

(2 extra staff so all can attend in am)

CAs handover to 2 seniors; seniors handover to 2 night staff

Manager’s office Hybrid: care plans electronic, other documentation paper

Exception reporting

CH 4

Large chain, purpose built (residents = 150)

7.45/8am (always)

7.50pm (always)

RN to RN by room, then RN to CAs (staff outside door, unless residents already up). (Extra staff so all can attend in am)

CAs hand over to senior CA before they leave their shift. Then SCA hands over to night RN. Night RN hands over to CAs

Room by room unless residents are up, in which case it can be flexible.

Hybrid: care plans electronic, other documentation paper

Systematic reporting on each resident

CH 5 Private (residents = 22)

Shifts: 7-2.30pm; 1-9.30pm; nights

7.15am (always)

1.30pm (always)

9.00pm (always)

Night CA hand over to day senior CA. Day SCA hands over to day CAs (who previously checked residents) and allocates work

Senior CAs hand over to afternoon shift CAs

Day senior CAs hand over to night CAs

Staff room (never in front of residents)

All electronic Tends to be exception reporting currently due to use of new electronic system

Any matters flagged up on the handheld electronic system as needing follow up are covered

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We observed 12 handovers and interviewed 27 staff (see Figure 1 for summary of participant job roles). Of those interviewed, 20 were female and seven were male. We provide only brief details of the participants to help protect anonymity.

Two main themes arose from the interviews and observations: descriptions of handovers and staff perceptions on purpose and effectiveness of handovers. These are discussed in turn below and compared across care homes and staff groups.

Descriptions of handovers

Handover practices were described by participants and viewed during observations. These are reported under the following four headings: timing and duration; who hands over to whom, and who participates; location; and content and artefacts.

Timing and duration

The timing of handovers throughout the day varied across the care homes. As Table 1 shows, CH1 had up to four handovers a day (but mainly two which are referred to as ‘sometimes’ happening at this time), CH2 and CH5 had three, and CH3 and CH4 had two. Staff members often reported the shifts as being 8am to 8pm, however, further discussion revealed that in some homes staff came in at least 10 to 15 minutes earlier, or stayed later, to be involved in the handovers at the beginning or end of shifts.

Figure 1: Summary of participant details

Across the homes, the duration of the handovers was reported as being variable depending on the business of the day and decisions about how information was shared:

We reckon that it shouldn't last more than half an hour, because otherwise it goes on ... but they do sometimes go on; depends on how ... what things is happening. It could sometimes go on into an hour, for the nurses especially, but not for the carers. The carers will just have a quick handover and then they will go on and do. (CH1, I1, Manager)

… it's so... well, it's time-consuming, this is the problem and they want to do it quickly because they're coming over and they want to finish it within 15, 20 minutes, so that they can go off their shift and go home. (CH3, I1, Manager)

Only give information that you need to get; you know, pumping too much information on someone that they don't need and they're not going to use, especially just for 15, 20 minutes handover. (CH4, I6, senior care assistant)

It's not the length of the shift which determines the handover, the length of the handover; it's what has happened during the shift. It may have been a shift where there's a lot to handover to those who are coming in. (Stakeholder 1)

In all the homes, managers and care assistants highlighted the importance of finding a good balance between handovers not being overly long, so as not to hold staff back from other tasks, yet at the same time being sufficiently thorough to ensure the safety of residents. The following quotes are illustrative of this dilemma:

Some nurses are much more elaborate, but I don't want too much elaboration; you need the facts and what is actually happening to that individual, not go overboard; we don't want that. (CH2, I1, Manager)

I just want the information that I need; nothing extra, because I've got so much to do the whole 12 hours, so I just need the relevant information. I think that's the way it should be. (CH4, I6, senior care assistant)

Owners/managers

Registered nurses

Senior care assistants

Care assistants8

49

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I think staff do understand that if they're giving us a quick handover which doesn't help anybody, anything goes wrong, it's going to come back to the handover. So I think people take it seriously, and rightly so. I might just add, they get paid for that time anyway. (CH4, I6, senior care assistant)

Whether staff were paid or not for handovers varied between the homes and was raised by several participants. In CH2 and CH3, some staff mentioned they were not paid to come into work early or leave late in order to attend handovers. In CH3, CH4 and CH5, some senior staff were paid for additional time to allow for a crossover of staff enabling incoming staff to attend handovers. This could mean longer hours for staff, which might be unwelcome to some. In CH5, the day was structured into three shifts with 15-minutes paid handovers for staff. In two other homes payment was not generally made:

Some of them, they are saying, oh, we don't get paid, this and that. I say, look, I come in my own time, specially early morning, they didn't ask me, so I just say, look, at least the work in the morning is not too heavy, because I start a bit early. (CH3, I4, senior care assistant).

Regular payment for handover was made to the senior staff in another home, since they were required to be present for this activity:

The seniors and RNs (nurses) stay an extra 15 minutes at the start and end of their shift and are paid for this … So the seniors, because they're the vital staff, so really it's like handover and then the seniors. Because the other thing is they do such long shifts, so it's nice that the carers can get out and home, so everyone arrives at eight, but technically, the carers go but the seniors stay and get paid for an extra 15 minutes. (CH4, I1, General Manager).

A manager in CH4 stated that if there had been ‘an incident’ staff might be asked to stay late; if this was the case then they would get paid for it:

But we don't actually want everybody to stay. If it's time to go home, I will say, okay, then, I'm here and the two night staff, I need help; you stay, you stay; so I'll maybe point out two

carers; I'll say, please can you stay back for a while? (CH4, I1, General Manager).

Interestingly, Stakeholder 1 reported that, in her experience, some care homes make it compulsory to have a handover before starting work with residents, but in other care homes this was not the case. This comment indicates that the well organised handovers observed in our five case-study homes may not always be the norm. A CH5 manager admitted that, very occasionally, a ‘hiccup in timing of staff meant a handover might take place in passing’, indicating that, in some cases, handovers might be more ad hoc than is generally presented in this report.

Who hands over to whom, and who participates?

There was variation between the five homes in who hands over to whom, and who participates in handovers – either regularly or occasionally (see Table 1). For the morning handover in CH1 (sometimes) and CH2 (always) the registered nurse or senior care assistant going off duty would hand over to all care assistants and registered nurses coming on duty. In the other homes (CH3, CH4, CH5), the registered nurses (or senior care assistants) and care assistants would hold separate handover meetings and then the registered nurse/senior care assistant would carry out a further handover with the care assistants. Where afternoon handover meetings were held, all staff were present in CH1; occasionally in CH2 but never in CH5. In the evening, the handover pattern was that care assistants updated the registered nurse/senior care assistant at the end of their shift, who then handed over to the oncoming registered nurse(s)/senior care assistants individually or together as a group with the care assistants.

CH2 Manager 1 explained she preferred to include all care staff members in handovers, if possible, because she thought care assistants were the best source of information about residents:

When you think of it, the bulk of the work is done by [care assistants], really, and they’re observing everything from how the resident is, from the way they're eating, their drinking, everything. So it is good to involve them and work together. (CH2, I1, Manager)

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A participant from CH1 also explained how this approach could benefit residents:

Yeah, because all service users are different. You might have someone that might not eat from me, but she might eat from someone else, do you see? So I think it's better how we do it like this. (CH1, I2, senior care assistant)

Another reason given in support of all care staff attending handovers was that they are a means of ensuring staff know about all the residents in the home, not just the ones they are charged with caring for, and could answer questions from family members about any resident. This was one reason why allocation of staff to residents (referred to by interviewees in CH2, CH4 and CH5) took place after handovers which according to Stakeholder 1 also encouraged staff to listen attentively throughout:

So how you will know if some family is coming in the afternoon and will ask you, ‘Did my mother … have his breakfast?’, so the patient is on another floor, so you won't know; the middle floor won't know the top floor, so if they are here in handover time, at least they will know. And any skin problem, any patient had a fall, or any patient has been constipated, has not pass urine, things that, so they will be aware of it. So handover is very important for everyone at one go, to sit all (emphasis) at the handover time, and to hand over. (CH2, I3, registered nurse).

The manager of CH5 also confirmed that if a thorough handover had taken place with all care staff present, it was easier for the senior member of staff on duty to allocate care workers to residents depending on their skills and knowledge (more relevant in the larger homes). The quote from CH4 below also refers to this matching process:

We don't just do a handover; we also give allocations out as well and so staff know who they are responsible for looking after and what they are responsible for doing, and so it's not just a handover they get. (CH4, I3, senior care assistant)

In addition to this, one participant mentioned allied health care professionals and others being included in handovers, but this was uncommon. In CH3,

the manager stated that the physiotherapist and/or activities manager might be involved. Another participant noted cleaners could be very well informed about residents and a useful source of information:

Then maybe the cleaner is there … they are expected to join in, depending on different places, as they should know quite a lot about the residents. (Stakeholder interview senior care worker, I1).

It was widely acknowledged, however, that when all members participated in handovers together, there was a risk that residents would be left unsupervised, as the following comment highlights:

Every shift, all the staff members attending the handover. The only way you can't have a handover is if we decide to ask someone to stay in the lounge with a resident that is at risk of falling and stuff like that, but still the information will be related to you after the handover. (CH4, I6, senior care assistant)

Alternative arrangements of registered nurses/senior care assistants handing over to registered nurses/senior care assistants separately and then cascading down to care assistants were reported by some participants as being safer for residents because all staff were not involved at the same time. These approaches were also viewed as saving time. In CH5, the handover process had been altered in this way, and there was no longer a handover where all members of staff were included, as the quote below illustrates:

In the past … all would sit in the handover, but we didn’t want people off the floor for too long. Not all care assistants needed to know

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everything. Seniors do the handovers [now]. And allocate responsibilities. (CH5, I2, deputy manager)

Another point made concerned the extent to which staff participated in the handover discussions or rather whether everyone simply listened to a senior member of staff. In some homes (CH2, CH3 and CH5), it was reported that all staff actively participated in handovers, while in CH1, this varied. In CH4, different reports were given from CAs working in different areas, as the following comments illustrate:

Oh, we [care assistants] just listen ... Because we don't want to disturb them [the nurses], we don't need to ... that is important. (CH4, I6, senior care assistant)

Gets everybody involved. Yes, gets all my colleagues involved. (CH4, I4, senior care assistant)

I have known carers in the past who didn't even know what a handover was; (they had) never been involved in care plans. They're only just carers; they're only there to change the pads and wash the residents, which I think is wrong. (CH3, I1, manager)

A few comments indicated there might be some friction or tension between registered nurses, senior care assistants, and care assistants over handover practices:

Everybody knows that [for] handover, we come in the office at ten to eight every morning, and at night time we don't let all the staff come in. (CH3, I4, senior care assistant)

Well, the nurses talk to us sometimes. You can pick some of them that are really friendly, and then, when we need some advice or something, they help us, but I think it depends which person … sometimes, even if they work long time, and then they ask some advice, they just look at you. That's why, for me, I don't even want to bother them; I'll ask somebody else … So it depends who is working. (CH4, I5, care assistant)

In CH5, one senior care assistant (I3) commented that, although all resident information could be

viewed on computers and on handheld devices, senior staff would only discuss information that was relevant to care assistants in the handovers to enable them to ‘get on with what they are doing’ – so, for example, medication would not be discussed.

Location

Handovers took place in several different locations within the homes, depending on factors such as whether it was an early or late handover; the residents’ disabilities or health conditions, and whether they could be left alone; the degree of confidentiality or privacy required for certain residents; or the presence of relatives or other visitors. There were mixed views about whether handovers were better undertaken in residents’ rooms – as in CH1 (sometimes) and usually in CH4 – or at the central nurses’ station (CH2 and, in CH1, mainly between registered nurses/senior care assistants), in the corridor (CH1 between care assistants), or behind the closed doors of an office (CH3 and CH5).

In CH1, handovers took place centrally at the nurses’ station, and also room-by-room, depending on the residents’ fluctuating conditions. The rooms of more independent residents were located on another floor, and these residents typically got up early in the morning and came downstairs, so the morning handover usually took place downstairs for some residents, and for others, in their rooms on the lower floors.

In CH2, handovers usually took place at the nurses’ station, which was in the lounge of the care home. However, if discussion was deemed particularly confidential – for example, relatives were visiting or sensitive information needed to be transferred – nearby rooms could be used:

I don't like to have handovers when residents' family are about, because if there's sensitive information and then you have all the ... it might be relevant to the individual family, but then it's not ... you share information, I don't feel that's right, and we always tend to go ... the nurses' station, because we've got an open plan in here, so if there is any visitors or anything, it would always be, you know, I've got a quiet room here, or we'll go in the conservatory. (CH2, I1 manager)

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In CH3, the handover meetings were held in the Manager’s office, behind closed doors:

I used to work in the hospital and my experience of the handover was every single morning … we went room-by-room with the doctors, with the nurses and we shared all the information from doctor, patient, but other patients could be in the room. I think it wasn't a good practice to talk about the residents in front of everyone else; here it's good because we talk about the residents in the office, the door is closed, no one can hear it, and the handover book, everything will be in there. Even if ... I don't know, the maintenance coming, or if someone's going to check the hoist, everything is in the handover – not only about the residents, everything. It's really, really good. (CH3, I3, senior care assistant)

I think it should be private and confidential, and in an enclosed place. I think the seniors know that as well, and the staff know that; we can't really discuss about residents out there, because they know about confidentiality and data protection and everything. (CH3, I1, Manager)

However, when this approach was used, the manager was keen to note that, due to a previous incident, emphasis was also placed on a ‘health and safety check’ of all residents by staff coming on duty and coming off duty, to ensure they were alive:

We check every single bedroom to check every single resident is alive, whether they're in the bedroom or not. That's the first thing you do to check. (CH3, I1 Manager)

If they find that maybe one or two residents, the ones who like to get up, are restless, they will say that they're not able to attend the handover, but they'll get the information from the senior. So somebody is looking after, so the residents are safe. (CH3, I1, manager)

In CH4, practices differed across the different units. There was a general policy to go from room to room to ‘see’ residents, but there was some flexibility depending on residents’ conditions, such as dementia, in which case the handover could take place at the door:

We don't really just want to take somebody's word by saying he or she's alright, so we go really to make a physical element and make sure everybody's alright, everybody's fine. So we go to each room to make sure everybody's alright, and with the handover sheet, explaining to us what has happened overnight and so on and so forth, so it's detail enough, yes. (CH4, I3, senior care assistant)

Personally, the one by the beds, I actually prefer it, because when I work, I always want to see residents within 45 minutes I've started work, so if you do the handover at the nurses' station, I don't feel safe. […] but people don't like it because it's time-consuming, especially if it's on different floors; it's not popular, that one. (CH4, I6, senior care assistant)

Demonstrating the variety of handovers even within homes, with different groups of residents, this CH4 participant described how handovers are flexible, depending on the circumstances:

Sometimes in the lounge, sometimes it's in the desk, because the residents is up and down, up and down here, so we don't pick the place where the handover, so we can see the residents, because especially here, it's easy there, the handover is not like the nursing that you have to go and stay there, in each room, because here it's not much to tell because they can see, they're mobile, they're talking, by the time they're giving the handover, somebody's calling, talking to you, the residents, so it's like a mixture. (CH4, I4, senior care assistant).

In CH5, care assistants coming on duty would have a quick look around the home to make sure all the residents were ‘okay’ before going to the office for the handover from the senior care assistant.

Content of handovers and artefacts used

Across the care homes, participants reported some confusion about the existence of written guidelines or procedural documents about handovers. Rather, managers and staff reported altering their approaches to handovers over time. Participants reported the type of areas they handed over without articulating any ‘rules’ about what was covered. One participant noted: ‘It all depends on where you go; different policies, how they

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deal with their own stuff’ (CH2, I4, senior care assistant).

While Stakeholder 1, a senior care assistant, commented, ‘Everything is defined different’, when asked about content, she then outlined the ‘usual’ areas covered in her experience of working in several homes:

You are looking at how much they have nutrition, what they've eaten, how much they've drunk, as much as you can say, and also the bowel movements and then also looking at if there's anything unusual about them … and also if they've started some new medication they may actually be required to look out for any changes. (Stakeholder 1, senior care assistant)

The content of handovers varied, depending on how they were distributed throughout the day. In CH2, where there were three handovers, the midday meeting was described as ‘detailed’ or ‘personal’ and also covered staffing and accommodation; whereas the morning handover was more of an update on how residents had been during the night and previous evening. Where there were two handovers, the morning handover was described as most detailed and necessary for communicating information for the day ahead. In CH1, the 2pm handover was mentioned as useful for staff working half days and was described as a ‘back-up’ to ensure nothing was being forgotten.

A difference of opinion between participants was also identified over the importance of systematically reporting on every resident during handovers (CH1, CH2, CH4) versus exception reporting (CH3, CH5), where only changes in residents or new information were communicated. In CH4, one participant (I4, senior care assistant) reported that in practice this was left to individual staff discretion.

To a degree, the appropriateness of these strategies might be expected to vary depending on ‘resident-dependency’ or need, and whether it was a nursing or residential home. However, some respondents considered it was good practice to always run through all residents, name-by-name or room-by-room:

If there are no concerns that night, you repeat each and every person, maybe through saying they actually remember there is something left out. (Stakeholder 1)

One participant in CH3 said they preferred it when staff went through all the residents in turn, but they were no longer doing this:

To handover every individual, it's time-consuming and staff need to go out on the floor, because a resident is at risk, so we do the major bits. So that's the only thing we could say handover to improve, is everybody give a run-down of everybody. We used to do it, and it used to take a lot of time. We used to but, otherwise, everything is okay. (CH3, I4, senior care assistant)

Meanwhile, observation notes for CH4 commented that content appeared to focus on the following:

The team went from room to room, checking nails (for any faeces) and heels for sores. The toilets were checked for cleanliness and room temperature. The handovers focussed on three aspects, mainly viz. pressure sores, daily living and medication.

The different care homes also varied in how they recorded information that was handed over. In CH1, notes were taken by care assistants on their own A4 notepads and were thrown out after the shift; in one observation no notes were taken by the care assistants as they said they would remember everything. In CH2, the handover sheets were A4 computer print outs with the names of residents printed on them and spaces to fill in key facts. These were filed in an A4 binder at the end of the shift and thrown out after a couple of weeks. In CH3, handover note sheets were not mentioned. Meanwhile, in CH4, ‘progress notes’ and ‘daily reports’ were identified:

Well, a progress note is basically like when you write about a resident. Like, whether he's been washed and dressed and so on and so forth. His daily activities, like eating and drinking well and so on and so forth; that's a progress note. A daily report is basically telling us what has happened. If it's a night shift and coming on duty in the morning, with a handover sheet telling us exactly what has happened on the shift and so on and so forth, so it's not really mentioning whether everything's been washed or whatever, that's a different sector. Progress notes, you'll write in detail what is going on for

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the resident throughout the entirety of the day. (CH4, I3, senior care assistant)

In general, CH4 seemed to have more varied and complicated processes due to its having a larger number of residents and a more hierarchical management structure compared to the other homes. As one participant commented: ‘I only know the process in my own area’. In this home, the care workers used a handover sheet which listed all the residents in a specific unit. One said:

Because we've got the handover sheets, we've got every person present's names and the DNRs (do not resuscitate orders) on the side and stuff like that. We've got the information that you need to know. So, if you look at that, for instance, in handover, if you're doing handover and you missed out a little bit for a resident, you could still go back to the room number and you could see the information that you might have been talking about and ask, and then you could always get information. (CH4, I6, senior care assistant)

The use of a clipboard (as would be used in some clinical settings) was referred to by one manager in CH4, although not viewed in observations.

In CH5, one participant (I3, a senior care assistant) described the interface of the handheld device as consisting of ‘assessment, care plan, a timeline, new record, charts, and preferences’. Handover comments were reportedly noted in the ‘timeline’ and ‘new record’ items. Within the ‘new record’ were dropdown menus – for example, whether a resident had been turned over in bed. Anything flagged up would automatically transfer to the handover notes, which would show up on a chart that could then be viewed by all staff members on their computers and handheld devices. The benefits of this were described by two members of staff:

It's made handovers quicker ... because all the information can be condensed onto one page; plus, you can associate it to the appropriate record – eg if a resident has done an activity. As the day goes, you keep adding to the daily record like a portfolio. This [the daily record] is the first point for care, if a person is on a food and fluid check would need to look at the chart. If circumstances change, go back to

check the chart. It's more effective: because we have the devices on us all the time, we have the information. We can refer back to any information we need. It's very quick, rather than writing and going through pages. We had someone to do training on how to use the system and were given a mobile to try. (CH5, I6, care assistant)

We used to have folders with your care plans, so it would be too time-consuming to keep walking up and downstairs every time we needed to write something down. So you would find that you would end up trying to remember all your information to write it down at the end of your shift or in the middle of your shift; whereas this way, you've got your phones in your pocket and you can record your information as and when it happens, instead of trying to remember it at a later stage … Previous to the phones coming in, if you had a very, very busy shift and you didn't get a chance to get upstairs to write your notes, you would forget, and then things got missed and information didn't get handed over and recorded properly. Not always, but there were times when it was a risk. But now it's a lot easier ... I think people tend to hand over, flag up more than necessary, and I think it is because it is easy, because it is right there. They think to themselves, I'll just put that in the notes now. So we tend to have more than less … I'd rather have too much than not enough or the right information. (CH5, I3, senior care assistant)

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Only one participant was critical of the handheld system and its ability to collect information throughout a shift, rather than collate it at the end. This participant stated that they missed writing, as it was hard to update the device as they went along, due to other tasks requiring immediate attention and IT glitches.

References were made across the care homes to a wide range of artefacts involved in handovers and recording or communicating information. These included care plans, handover sheets, progress reports, daily resident reports, daily notes, handover book, communication book, GP book, home maintenance book (for the handyman), medication charts, medication books, day book, diary, check list, progress notes, fluid chart, positioning chart, reposition chart, cream chart to prevent pressure sores, hoist need chart, body map, general food charts, and specific food intake charts for residents losing weight. In CH5, it was reported that everything was electronic, although a paper diary was still used, indicating there may still be some duplication of record-keeping. Those items most often referred to were a communications book and a diary. In the care homes, who was able to update the different artefacts was referred to – for example, in CH5, participants noted all staff were able to update all areas on the system, whereas in CH3, staff were very clear this was the role of senior staff only. In other homes, this information was less clear or confused, suggesting this could be an area of ambiguity.

Handover processes were dictated to an extent by the use of handheld devices in CH5. The manager stated that a key benefit of the electronic system was that it allows much easier recording at the point of delivery and enables the home to provide prompt and detailed written evidence of any incidents (for example, when a local authority requested notes on a resident for a whole month, then what might have taken a day to produce could be collated and sent in minutes). Other features include the ability to take photos, which reportedly adds spontaneity and evidence to families that activities have taken place (when, for example, a resident cannot remember if they have participated). This feature also enables staff to record information such as bruises. It was said to save paper and printing costs.

Apart from complaints about network coverage, informants were generally positive about the electronic system in CH5 as a way of collating all

the information needed in one place, and one care assistant thought it had improved resident safety.

Finally, residents with different levels of disability or abilities to self-care may require different approaches to handover, and it might be expected that homes focusing on personalised approaches would have varied processes in place for handover as a response to the needs of their residents. But across care homes (CH1, CH2 and CH3), the attitude was that handovers were not generally carried out differently for residents with particular needs – for example, those at end of life (although more professionals might be involved, typically a palliative care team; and in one observation the handover discussion took place after a visit to the bedside of the dying resident). It was only in the largest care home, CH4, that staff stressed that residents had different needs and handovers were adapted to this; for example, CH4 had a dementia unit and handovers were reported as being carried out differently for certain client groups or those in receipt of care rather than nursing care:

Interviewer: You've talked about there is some palliative, some with dementia, some with cultural needs. Is there a different approach in handover?

Manager: Yes. I think, for the dementia residents, I don't allow them [the staff] to go into the rooms; I've stopped that. At first, what happened was that they used to go into the rooms, but then if I was laid in bed at home and six, seven people walked into my room in the morning, I'd be a little bit distressed because ... in a hospital you see it when you come round the edge of the beds, you expect that, but in a dementia environment, you don't understand why these people are in your room. Some do, some don't, because they have different capacity, but actually, if you walk in to a residence and you're talking but you've got dementia, how do you digest that information they're telling you? So you could unsettle, could harm them.

Interviewer: They become disorientated?

Manager: Exactly. So that practice has stopped. Not all of it, because sometimes, if you've got a sick resident that has dementia, you do have to, but what we do is just reduce it

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to the senior and the nurses that go in, and then we communicate that information. (CH4, I1, manager)

From the descriptions above, it is clear that the content and tone of handovers vary across care homes, depending on the prevailing culture. But handover practices also seem to depend on individual personalities and preferences. For example, in CH2, the individual nurses’ own styles were viewed as important, with one staff member finding time to focus on one resident having a ‘joyful’ time watching television as part of the handover or another flagging up signs indicating a possible mental health problem might be developing. As a manager noted:

So it could be you've got a brand new qualified nurse that might not be as experienced, so it really is who is the person on duty, and how have they been trained, inducted, and do they know the standards expected (CH4, I1, Manager)

Staff perceptions on the purpose and effectiveness of handovers

All staff: communication ensures continuity and safety – ‘it’s part of the job’

Most striking in our study was the importance that all staff groups placed on the handover as an accepted, intrinsic part of care home routine. For some care assistants, discussions about handover seemed to involve making tacit knowledge overt, and some respondents felt the process was an obvious part of the job. There seemed to be a general acceptance that staying longer for handovers, and even lack of pay for handovers, was ‘part of the job’, and few complaints were made about having to remain late if there was an emergency:

Everyone sees it as a necessary part of the day, and that is part of our routine; that is what we do every day, so it's seen as quite normal, really. (CH5, I2, manager)

It's just part of the job. (CH3, I1 manager)

So I know it's part of the job and I assume they know it's part of the job. So it's duty-bound. (CH3, I5, care assistant)

It's part of our job. It's part of our care and we can't do right and good care if we don't have this handover. (CH4, I2, registered nurse)

Handovers were treated as a serious, focused meeting by several participants, and there was little time for any social communication unrelated to care home business in any of the five homes observed, although one participant in CH3 stated it was ‘a laugh’ (see below) and one participant in CH5 stated the atmosphere was ‘jolly’. One exception to the general perception of seriousness was an agency (temporary) care assistant in CH2 who was seen arriving late and then not paying attention, and was reprimanded:

And we have a laugh with our handover, you know what I mean? It's not ... we're doing our work but it's nice for us all as a little group to sit there and have a morning ... Yeah, because then we're busy. Once that handover is finished, we're just busy. I mean, we're paired up, but we're still busy, so, yeah, it is nice, our handover. (CH3, I2, care assistant)

Across the staff groups and homes, participants referred to communication, continuity and safety as being the main aims of handovers. Communication was referred to as communicating things that needed to be done, communicating clinical information and communicating new information. Interestingly, one manager (CH3) stated too much focus on handovers could undermine the importance of daily continuous communication about updating on residents’ status. The manager in CH1 also talked about handover as communication in a practical and physical sense – for example, that the keys (eg to medicines, entry systems or store rooms) were also transferred from one worker to another – ‘and this is why it is called handover’. Another manager expected staff to be questioning:

I'd expect if a senior was explaining something that a care assistant didn't understand, I would expect the [care assistant] to turn round and say, Sorry – which they do – I didn't understand what you meant; what did you mean by that? Can you explain it a different way? It's making sure that you're giving out that information to people that ... you know … we need to make sure we give out information to her in a way she understands. Don't use words

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that people don't know what they mean. (CH5, I2, deputy manager)

Participants agreed on the importance of handing over verbally and also recording accurately:

[The] most important thing is whatever is written should be accurate and also pass orally. (Stakeholder 1, senior care assistant)

People do forget, even if you've been told orally, then they follow that in writing. So therefore the two things that you should have, you should have a written documentation as well as a verbal, so oral, verbal and written, tends to ... the information is passed much better. (CH1, I1, manager)

One matter that was raised by a small number of participants was language competence among some staff for whom English was not their first language. One participant, herself not from the UK, commented:

Actually … the language can actually affect the handover. Some are struggling to write, so doing handover it's like, if they think ... it's very minimal, because that's all they can say; they can't really make it very detailed because they don't have the quality ... maybe the language is too ... how they express this ... language is actually the level of competence of English can affect the quality of the handover. (Stakeholder interview 1, senior care assistant)

A nurse stated it was important therefore in handovers to use simple language:

I would say clear, concise and not too ... I mean, the words we use, as well; we can't

use too big a terminology that one person understand and the rest don't, they're lost. I would say very clear, concise and simple to understand for everyone and have the attention of everybody, draw the attention. (CH2, I2, registered nurse)

In response to being questioned about this subject, CH2 manager stated that younger nurses and especially those from mainland Europe were more keen to use IT, but this did not impact on their handovers. A participant from CH4 reported no staff communication concerns, although in this instance many residents and staff spoke the same Asian language, which may have made this situation more straightforward:

Also, sometimes I need the staff to translate to me because I don't know (the language), so that's why we have in that part, only the Asian staff. It's very easy for us, for them, to communicate. (CH4, I4, senior care assistant)

Ensuring continuity of care for residents was viewed as an important purpose of handovers. CH5 manager reported that the electronic system had improved continuity of care as well as enabling staff to spend more time discussing issues rather than systematically catching up.

Staff frequently referred to returning to work after leave or holidays and how they needed updating on what had happened to ensure continuity of care for residents was maintained. Handovers helped with this updating:

The night nurse in the morning will handover to use all the findings which he has been through all the night. So who has slept well, who has opened bowel, who has not had medications, who was agitated, whose dressing is change, who had a fall, things like that, yeah. So it's like a continuity of the care, so that we can follow. (CH2, I2, registered nurse)

The safety of residents was reported as being crucial by all categories of staff:

It’s a rolling and on-going thing. If a staff member was off for three days and if a resident is on antibiotic … the concerned, caring staff should know about it. So if this information is not handed over, then it is risky. To keep residents safe. Saves staff from just carrying on

Photo: British Red Cross

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without considering the changes but helps to personalise care. (CH3, I2, care assistant)

Managers’ and nurses’ perceptions: management, team-building and training

When asked about the purpose of handovers, managers reported additional areas in comparison to other staff, and these included organisational issues such as team-building, team supervision, matching care assistants with residents, ensuring good skill-mixes, sharing workloads, addressing workforce or personnel issues, and staff training, as the following extracts highlight:

Producing an action plan for the day, isn't it? (CH3, I1, manager)

Mainly to know they're working as a team, not just information. And ... making sure everybody's fine and happy … I've sent people home sick because they come in because they didn't want to ... It's nice to see the staff, to even ask if they've had a nice holiday or whether they've got any concerns … I can ask them to see me afterwards, or they may want to see me afterwards about some sort of personal issue ... (CH3, I1, manager)

Especially if there's things that hasn't been done properly and then if you tell them. Of course, if you tell me something I haven't done properly, I will feel a bit ashamed, so if you tell me, then it will click and then next time I will be more careful, just trying to do it a bit better. So I think this also it helps, because when I handover I don't point to this, despite I know this one hasn't done it properly, but I will just generalise it ... (CH4, I1, manager)

Interestingly, the manager of CH4 reported the importance of training and how they felt this had improved handovers in the home:

I would say, 15 months ago when I walked in, it was abysmal; now it's successful. And the reason it's successful is because, one, my complaints are down, clinical care is good, we've reduced hospital admissions, we work exceptionally well with our partners and we have some very extensive, positive feedback. I think the fact is that they're now structured. It is at the start of the shift. But also, I think

we've not just been static in the eight o'clock shift as well. We can do a handover between ... 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 say because they've got the sheets, they've got the information, because they know it's expected, so I think the good thing about it is that they've developed themselves, so the staff have developed themselves. (CH4, I1, manager)

Another manager in CH4 also noted their role as taking a more holistic, personalised approach rather than focusing on clinical care:

When I wake up in a morning, I just don't think have I got a grade two pressure sore. How am I? Did I sleep? How and I feeling? Am I miserable? Can I get out of this bed? So that's the reason I always look at handovers. … I think when people come into nursing homes, we de-identify them and they become a property. And I really say that ... I don't say that with any disrespect, because they do; it's like ... you forget. I've been in hospital and actually, you know, can I look at your ID band, that's important but actually, I'm more than an ID band. (CH4, I1, manager)

One participant highlighted the importance of handovers for making announcements to ensure all members of staff were aware of changes, especially if they had been on leave:

Someone may only work Friday and Saturday, so some information can actually have to be repeated over and over and over, to be sure … Handover can be platform for major announcements which can't wait for meetings. (Stakeholder 1,senior care assistant)

Meanwhile, most nurses were more focused on clinical aspects of the handovers as well as their leadership role:

Because if we have a good and right handover, we know if something happening in health condition, with something change, and we can give a good and right care. It's very important. (CH4, I2, registered nurse) Say, for example, somebody's medication is over, it happens, and then when the cycle medication

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is coming between. So, like, this morning [registered nurse giving the handover], said one medication is due for night, so this is important of handover, so we can follow it up. (CH2, I2, registered nurse)

In the observations, we noted that some of the registered nurses would be writing furiously during the handover. One commented:

I would empower people, as well, that they feel integrated into the handover and make sure 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 like that kind of handover. (CH2, I2, registered nurse)

However, another referred more to listening:

[I] know everything, because I'm here all day. I know everything, that's what I was trying to ... I'm following [registered nurse giving the handover], but I know, so I'm doing my doctors’ round book, the communication, what had happened, during yesterday, I was off, so I'm checking what the communication was, because I just follow it; just I'm listening about whoever had a problem. (CH2, I3, registered nurse)

Care assistants’ perceptions: resident safety and being prepared – ‘so it's not like going into the wilderness!’

Answers from care assistants about the purpose of handovers focused on ensuring the safety of residents, being prepared and accepting responsibility. Participants stressed that very old or vulnerable residents could become seriously ill quickly and staff needed to be constantly aware of these risks:

‘I mean, the elderly, their condition can just change’. (CH1, I2, senior care assistant)

These old people, all 80, you know, 80, 90; we have 100 years old. You don't know any five minute, anything happen. Because I have experience here, so that's why. It's good, you know, in the morning and before you leave and you check all over and they're fine. They're fine, yeah. (CH4, I6, senior care assistant)

… if you don't give the handover, how do we know that the residents, someone is still ill, but everybody, sometimes it's different. So they're okay, and then after a few minutes they feel sick, so that's why ... for me it's really good to have the handover. (CH3, I4, senior care assistant)

Care assistant participants also stressed the need to be prepared and the risk of going on a shift without having advance knowledge of a resident and any changed circumstances:

Because it [handover] really enables us to prepare ourselves for the day as well. (CH4, I3, senior care assistant)

You don't want to approach a patient you actually don't know ... how can that patient swallow; he could find it difficult to be swallowing and I don't want to go and say, okay, I'm going to give this patient normal food when this patient is on a purée diet, so you have to know everything before you actually approach. (CH2, I4, senior care assistant)

So you don't have to waste time in looking for what the problems are, understanding what's going on. You know exactly what you're heading to. It's not like going into a wilderness, you don't know what happening. (CH3, I4, senior care assistant)

It's got to be done. It's important, because we do also have annual leave, so when we've gone on annual leave, and we come back, we could be on annual leave for two or three weeks; there's been changes, so we may go to the floor and we don't know nothing, so I think the handover is very, very important, especially if we've got a new service user; that service user could have come in at four o'clock. I'm not here, so I know nothing about that person, which I need to know because, doing breakfast, I need to know if they're diabetic, if they're on purée, if they can have cornflakes. (CH1, I2, senior care assistant)

Some staff felt conscious of being responsible for any problems with a resident if they had failed to handover effectively:

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If things go wrong, you have missed on something by not handing it over, it could have very bad consequences, so it could actually result in neglect or something, because you did not handover that. (Stakeholder 1, senior care assistant)

Staff in CH4 in particular seemed conscious of this point:

But it's just a question of ... if they don't say ... if you think you are saying too much, better say too much than not say, because who knows how it's going to happen, what's going to happen later on? So if some people might leave out a few things, because they think they're minor, and then they get picked later on and they say, how come this was not written, or this wasn't handed over? (CH4, I7, care assistant)

If you don't give the handover, how do we know that the residents, someone is still ill, but everybody, sometimes it's different. So they're okay, and then after a few minutes they feel sick, so that's why ... for me it's really good to have the handover. (CH4, I4, senior care assistant)

I think so, because, as I said, if they don't take the handover, they don't know what's going on and they don't know what to do if somebody is sick. So if I don't give the handover, and say so-and-so is sick, they wouldn't know what's happening, so they will panic. They say, ‘what's happened here?’, and that's why the handover, for me, the handover is good. (CH4, I4, senior care assistant)

Making sure that the right information is being handed over, that things haven't been forgotten and that people are aware of the information that they need to know. So they can walk away knowing how to do their job and how to look after the people they are responsible for looking after. I think if the staff walk away from their handover and they don't really know what they're doing, that is an unsuccessful handover. (CH5, I3, senior care assistant)

Perceptions of all Staff and the SCWRU Service User and Carer Advisory Group on key elements of effective handovers

Across the care homes in this study, managers, registered nurses and care assistants were generally content with their handover practices. Participants maintained that it was important that information that benefited residents (such as information about insulin levels) was passed on during handovers. Key elements of an effective handover were identified by the different staff groups, stakeholders and the SCWRU Advisory Group members. However, not surprisingly, there were differences of perspectives. Care assistants highlighted the importance of being given the chance to attend handovers without interruptions, but also of being able to participate in discussions or clarify questions:

So we have to be punctual, we have to listen carefully, we have to follow it up and we have to handover to the others as well when they come. (CH2, I4, senior care assistant)

[It is important] people listen, have the time to do it, understand the information and feel supported. (CH4, I1, manager)

I think the best thing about handovers is that it's both formal and informal. You can have ... it's not so rigid that you have to stick to specifically what's on the screen [handheld device]; you can go into a discussion about it, so I think that's quite good because, if you have a discussion about something that's happened one day, you may find that there may have been a similar problem, or something else happened on a different day that you didn't know about those, you can just ... it's not in there, it's formal enough to get your point across, but it's not so formal that you can't speak your mind and ... (CH5, I3, senior care assistant)

Both managers and care assistants also argued that information had to be comprehensible:

That is clear and understandable and one where you feel free to ask questions if you don't understand something. (CH5, I6, care assistant)

While the handover process was generally an internal matter, there was evidence that they were sometimes observed by CQC inspectors.

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The manager of CH2 noted that a recent CQC inspector had stated they should be more personalised in their handovers and they were trying to take this approach. During observations in this home, registered nurses were observed making holistic references to residents (about their general wellbeing) and appeared to be responding to this criticism.

In CH3, a couple of comments were made about staff being late that emerged in discussion of handovers:

Not everyone take it seriously, the handover and few staff they running late and they not here at the time, so we start the handover and then they arrive five minutes later... I think everybody needs to be there in time, not two minutes later, not five minutes later. Yeah, this is a problem. ... if you start the conversation, the shared information and they just disturb us when they coming later. (CH3, I3, senior care assistant)

Meanwhile, in CH4, the manager concluded that staff training had improved handovers hugely, with staff being ready to hand over at any time if they were questioned about a resident; complaints and hospital admissions had reduced as a result.

As noted above, the matter of resident safety during handovers emerged as important to managers and staff. The following comment highlighted the need to respond to possible problems during handovers:

… as you can see this morning, as well, the doorbell would be going off; sometimes that can be a little bit of a disturbance; the room bells will be going off, so we have to approach that very promptly, very quickly, because it could be ... because the night staff are already gone, so while the handover is taking place, it could be a bell going off, somebody have to get up because we have to respond to that because we don't know what is taking place inside of their room. (CH2, I4, senior care assistant)

In CH5, one participant highlighted the downside of using handheld devices to record information for handovers, as they might be perceived as a threat or as confusing by care home residents. Some staff members made efforts to address this:

Sometimes pen and paper is less threatening than taking something out of your pocket. You have to be in tune with the person you’re with. Either write nothing when you’re in the room, but sometimes they say ‘Why aren’t you writing that down?’ And if you write it in front of them, you can show them. I guess they’re not used to it [computers]. It’s not part of their generation. They might want to know what else you have written down there. Some think you’ve got a mobile phone and that’s rude. Let them see you’ve taken a note and then upload it later. (CH5, I4, senior care assistant)

Other, more general comments included the importance of having a stable staff group, which made handovers easier due to trust between colleagues who could rely on each other to pass on germane information (CH1, I5), and the problem of key-person dependency, where quality of handovers could decrease if one person who is skilful in handovers leaves (CH4, I1, manager).

Finally, participants from the SCWRU Advisory Group highlighted the role of handover notes in enabling a resident’s family to check ‘what’s paid for is being provided’ and that an agreed care plan was being implemented. Handover notes were also viewed as assisting follow-up of certain matters if necessary. They could also help provide an indication of quality of life of the care home resident and were viewed as potentially helpful in tracking a resident's wellbeing and enabling the family or friends of a resident to request a review of a care package (funding for the care home place) based on evidence. Such system-wide considerations did not emerge in the interviews or observations, or the literature.

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Summary of indicative elements of an effective handover from participants’ perspectives 1. Being able to listen/hear – not too many

distractions or interruptions2. Understandable and clear communication3. Opportunity to ask questions; feedback from

everyone listened to4. Punctuality of staff5. Attention to confidentiality and respecting

residents’ dignity 6. Production of transparent and readily

available written records (possibly enabling family to review and monitor changes)

7. Viewed as important by management8. Knowing what is expected9. Being valued activities for which staff are

paid

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Discussion

Study limitations

There are acknowledged limitations to the study. Firstly, the manager’s (or wider provider’s) approval was necessary for our study, so our sample may represent a group of homes with an interest in this topic and confident in its practices. All the homes that agreed to take part had received ‘Good’ CQC reports, while those homes we approached that had less satisfactory CQC reports declined to participate, again suggesting that our sample may represent high-performing care homes where it would be expected that handovers (and other practices) would be effective. Secondly, individual staff may have deliberately improved their performance while being observed (the Hawthorne effect), or may not have been entirely open with researchers due to lack of trust or lack of time, which could have influenced our findings. In one observation the researcher was accompanied by a senior member of staff who had stayed late to welcome the researcher. The views of residents are not included in this study and these would be important in providing another perspective.

Our study of five care homes has underlined the variations in handover practices in terms of frequency, duration, location, who hands over to whom, and content. This variation might be expected as the study included care homes and care homes with nursing and therefore residents with a wide range of needs, including those who were thought to be close to death. (The distinction between homes with and without nursing may not be substantial given the increased frailty of residents in recent years (Wild, 2016)). Variation might viewed an indication of good practice, demonstrating a more personalised approach to residents and one more in tune with the needs of the staff team. On the other hand, it might be expected that some good-practice guidelines would have been established in this area given the substantial time taken up by handovers and the comments on handover practice made by the CQC.

This study raises several questions about

current practices and their evidence base. For example, is there an optimal time for handovers in care homes? Is any one location for handover better than others – for example, room-by-room (or ‘bedside’) handovers may enable residents and their families to have more opportunities to be involved in and to monitor care provision (Tobiano et al., 2013), they may provide assurance in respect of residents about whom there are concerns, but at the same time may be more time-consuming and costly. Though handovers that take place behind closed doors provide greater privacy, evidence from healthcare locations (see Tobiano et al., 2013) suggests staff may be more concerned about maintaining privacy than residents and their family members. How can managers balance thorough handovers with timeliness? What is the best way of ensuring resident safety while handovers are taking place (should additional staff be employed, or some staff be left on duty while others are in the handover meeting whocatch-up later in the shift)? How can positives such as team-building and knowledge-transfer of whole group handovers be balanced with negatives, such as possible increased risk to residents of all staff being ‘off the floor’? Responses to these questions possibly lie in a combination of flexible practices which several of the homes in our case study were using – for example, handovers were seen to take place with different staff groups in different locations depending on residents’ movements and who was visiting that day. At present, the evidence base is limited and the impact on outcomes for residents is purely speculative.

An Australian research study has highlighted how the shift pattern operating in a care home has implications for numbers of handovers being undertaken at key times of the day. Older people in that study reported some frustration at not being assisted during handovers and understood this as contributing to their spending longer periods in bed than they wished (Luff et al., 2011).

An interesting point raised by this study is ambiguity over the term ‘handover’ and

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whether it refers to the handover of residents or responsibilities, or artefacts – eg keys, medication responsibility or notes? Even the word ‘handover’ might be viewed as a derogatory term which de-personalises residents by implying they are non-animate and can be passed from one care assistant to the next, a point possibly inferred by some participants who also argued that ‘handover’ is better viewed as a continuous process throughout a shift, rather than something that happens at the end of the working period. Spending a long period of time at the end of shifts, writing up notes, is felt by some to be sub-optimal and leads to inaccurate reporting. Supporters of digital handovers use this argument to promote their services as being safer. An alternative view would be that time lapses mean that those tasks that are more important than others are clarified after reflection. Gaskin et al. (2012) compared information exchange in four nursing homes in Australia which used a variety of paper and electronic systems, including point-of-service devices and found IT could potentially reduce the time spent at handover, because staff would not have to search for information from different locations. However, they found use of these systems varied considerably and actually either made no difference or even increased documentation time. The authors argued that clear understanding of the purpose of the information exchanges and existing processes were needed for them to enhance current practices.

Staff across the homes in this study voiced their commitment to the importance of handovers, which they viewed as an intrinsic part of care work and of great importance in communicating information to ensure the continuity of care and safety of residents. The fact that staff in some of the care homes were willing to attend despite not being paid for the time possibly demonstrates their value to staff. Several care assistants reported handovers were crucial for preparing them to go on duty and taking responsibility for resident safety. Some managers and registered nurses further reported handovers had additional uses as opportunities for team-building, ensuring members of staff were allocated appropriately, organising human resources and elements of staff training or information sharing.

Other recent research conducted in a different Australian nursing home found that handovers can be an area of tension between registered nurses and care assistants, as it is the nurses who decide what information they share, and this can lead to friction

or disputes (Bennett et al., 2015). This matter has not been explored in the UK context.

In all five sites, staff stated handovers were effective and identified key elements of a successful handover as enabling staff to listen without too many distractions, being understandable and clear, providing an opportunity to ask questions, and respecting the privacy and dignity of residents. Given this, it is worrying that Burns et al. (2016), examining what they termed ‘cost-cutting exercises’ in 12 care homes in England, found handovers were being affected. They concluded that cut-backs were negatively affecting job quality by reducing pay and changing contracts to remove breaks; requiring staff to work longer hours or shifts; reducing staff numbers (increasing staff-to-resident ratios); using less qualified staff, especially diminishing numbers of registered nurses; and reducing staff discretion over their work, such as forbidding staff from having a cup of tea with residents. The authors suggested that this was inversely related to the provision of ‘person-centred’ support and indeed prompted more ‘custodial’ approaches to care, where the focus is on safety rather than individuals. They argued that cuts to labour were eroding the quality of workers’ jobs in all 12 homes; quality of care was being maintained in seven of the homes, but in five, their assessment was that it had deteriorated. Specific to our present study, we note that Burns et al. (2016: 999) found that, in one of the 12 homes in their study, care assistants were no longer allowed to attend handover meetings and rather formed ‘informal huddles’ to discuss residents; while in another care home, payment for attendance at handovers had been removed. There is some evidence of these practices in our findings; indeed, non-payment for handover attendance seemed to be long-standing in two homes. As we reported above, in another two homes, handovers had changed to exception reporting, which reduced their duration, and in one of these homes senior staff had recently started handing over to their peers (senior staff) rather than to the whole group. The reasons given for this latter change were to save time and improve safety for residents, and that the need for such a thorough handover was reduced with the introduction of the handheld devices. These may represent efforts for greater productivity in the care sector, since the managers did not report that these changes were directly cost-cutting.

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Summary

This report was produced at the beginning of 2017, a time of significant policy interest in the financial sustainability of social care overall and of many care homes in particular. This study contributes to this debate by providing evidence that care homes are highly heterogeneous, but that the wellbeing of their residents is an important concern for many frontline staff and their immediate managers. Handovers are described as an essential tool to ensure safe, high-quality and dignified care for the residents in care homes. We witnessed active consideration of residents – late at night, early in the morning – and they were ‘known’ as individuals to the staff. While there are care homes where practice is not good, we need also to acknowledge and celebrate good care homes and the people who work in them. Further studies of handovers need to build on the current strengths of practice in many settings, and staff, residents and family members could be involved in defining what is effective, feasible and suits the culture of the care setting.

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