How do handovers happen?
A study of handover-at-shift changeovers in care homes for older people
Caroline Norrie, Valerie Lipman, Jo Moriarty,
Rekha Elaswarapu and Jill Manthorpe
Social Care Workforce Research Unit
February 2017
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.
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.
Contents
Executive summary................................................................................. 4
Introduction.............................................................................................. 5
Background........................................................................... 5
This study.............................................................................. 5
Observations and interviews in five care homes............................... 8
The sample: five care homes............................................................... 9
Descriptions of handovers.................................................................11
Timing and duration...............................................................11
Who hands over to whom, and who participates?................ 12
Location................................................................................ 14
Content 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’........................................... 19
Managers’ and nurses’ Perceptions:
management, team-building and training.............................. 21
Care 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............................ 23
Summary of indicative elements of an effective handover from
participants’ perspectives............................................................... 25
Discussion................................................................................................ 26
References.............................................................................................. 29
3
Executive summary
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:
4
•
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.
•
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.
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).
5
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
6
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-AssessmentRecommendation (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
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.
7
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
8
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.
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, forprofit 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 paperbased 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/notfor-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.
9
Table 1: Summary of handover practices (RN = registered nurse; CA = care assistant)
Content
Timing
Who hands over to whom
Location
Processes
Systematic reporting
on each resident?
Items commented
on?
8am (always)
RN to RN; RN to CA
Nurses station/or
walk around room
by room
CH1
9am (sometimes)
Privately owned,
family run
Nurses to CAs after
breakfast.
2pm (sometimes)
Handover to CA coming
on.
(If room by room,
CAs listen outside
the door – no need
for 9am handover)
8pm (always)
CAs to RN; then RN to
RN
8am (always)
Night RN to all staff (RNs Nurses’ station/
and CAs)
staff room,
or lounges if
confidentiality
needed
Day RN to all staff at
12am
(residents = 50)
CH 2
Small chain
12 midday
(sometimes)
Mostly paper
Systematic discussion
of each resident
– notes made by
incoming nurse/
senior care workers,
keys passed over
Mostly paper
Systematic discussion
of each resident
following printed
sheet with names and
inputs/ outputs
(residents = 60)
8pm (always)
CAs to RN throughout
day and at end of shift.
Day RN hands over to all
staff (RNs and CAs)
7.45am (always)
All staff (day and night
shift) and the Manager
CH 3
7.45/8am (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)
7.50pm (always)
CAs hand over to senior
CA before they leave
their shift. Then SCA
hands over to night RN.
Night RN hands over to
CAs
7.15am (always)
Night CA hand over to
Staff room
day senior CA. Day SCA (never in front of
hands over to day CAs
residents)
(who previously checked
residents) and allocates
work
CH 5
Private
Shifts: 7-2.30pm;
1-9.30pm; nights
10
Hybrid:
Systematic reporting
care plans
on each resident
electronic, other
documentation
paper
CAs handover to
2 seniors; seniors
handover to 2 night staff
(residents = 150)
(residents = 22)
Room by room
unless residents
are up, in which
case it can be
flexible.
7.50pm (always)
CH 4
Large chain,
purpose built
Hybrid: care
Exception reporting
plans electronic,
other
documentation
paper
(2 extra staff so all can
attend in am)
Non-profit/
voluntary sector
(residents = 26)
Manager’s office
1.30pm (always)
Senior CAs hand over to
afternoon shift CAs
9.00pm (always)
Day senior CAs hand
over to night CAs
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
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.
Figure 1: Summary of participant details
Care assistants
6
Owners/managers
8
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)
9
4
Senior care
assistants
Registered
nurses
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.
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)
11
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
12
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 casestudy 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)
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
13
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
14
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)
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
15
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)
16
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 timeconsuming 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
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:
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)
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
17
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
18
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
to the senior and the nurses that go in, and then
we communicate that information. (CH4, I1,
manager)
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)
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:
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:
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)
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
19
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
20
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
21
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)
22
… 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:
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.
23
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:
24
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.
Summary of indicative elements of an effective
handover from participants’ perspectives
1. Being able to listen/hear – not too many
distractions or interruptions
2. Understandable and clear communication
3. Opportunity to ask questions; feedback from
everyone listened to
4. Punctuality of staff
5. 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 management
8. Knowing what is expected
9. Being valued activities for which staff are
paid
25
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
26
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
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 depersonalises residents by implying they are nonanimate 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 pointof-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 ‘personcentred’ 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.
27
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.
28
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