A simulation of patient handovers in a safe environment can help student nurses to develop the skills and confidence needed to carry out this process effectively
This article outlines the potential impact of ineffective handover skills on nurses’ confidence, competence and coordination, as well as on patient safety. It focuses on how student nurses can develop their communication skills by looking specifically at how the University of Derby used simulation to teach pre-registration student nurses effective handover techniques.
Citation: Collins G (2014) Using simulation to develop handover skills. Nursing Times; 110: 8, 12-14.
Author: Guy Collins is senior lecturer at the University of Derby.
- This article has been double-blind peer reviewed
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Poor handover and communication between professionals has a negative impact on patient safety (Wong et al, 2008; World Health Organization, 2007). The Keogh review (2013) gave examples of poor-quality handover of patient care at several trusts in the UK.
However, not all professionals lack the skills to hand over patient care effectively, and confidence, competence and coordination of these skills varies between them.
The causes of handover failures cannot be attributed to just one professional group or form of handover, for example between nurses during ward rounds or shift handovers; failures also relate to communication breakdowns between different professional groups. Rather than communicating information only within their own profession, all clinicians need to adopt a multidisciplinary approach to handover to ensure the successful ﬂow of information and effective continuity of care (British Medical Association, 2004).
Effective handover should include the patient and relatives or carers, to ensure they are kept informed and involved in decisions around the care plan. This follows recommendations by Francis (2013) who stated: “Regular interaction and engagement between nurses and patients and those close to them should be systematised through regular ward rounds.”
Pre-registration students’ handover skills
One of the four domains of the Nursing and Midwifery Council’s (2010) Standards for Pre-Registration Nurse Education is developing communication and interpersonal skills. It is clear that these skills form a large part of student nurses’ preparation for registration.
However, what is less clear is how student nurses can learn and develop these skills, and how to give them the opportunity for safe rehearsal, and the ability to transfer them into their own practice.
The academic team at the University of Derby undertook a review of how effective the university was at developing student nurses’ confidence, competence and coordination of patient handover skills.
The review consisted of a student feedback audit of their experience and self-awareness related to handover skills. It included two cohorts of second-year students with a variety of placement experiences. All participants had undertaken placements in both primary and secondary care and had been exposed to varied clinical environments where handover would be used for different purposes and is carried out in different ways, such as verbal face to face, telephone and audio recorded.
The audit found several issues that prevented students from developing their competency in handing over information. Student feedback comments included:
“I have never been asked to give a handover.”
“I get nervous speaking in front of other people so if I can get away with it, I avoid doing it.”
“I felt all right giving handover to my mentor but I don’t think I could handover to a doctor.”
“I don’t like talking to relatives, I never know what to say.”
“I stumbled with what I was saying - it put me off trying to do it again.”
“My mentor kept adding bits to what I was saying, which really knocked my confidence.”
“I realised after I had given a handover once, I missed lots of things I should have said.”
We identified several key themes based on the students’ feedback:
- Ambiguity of what constituted a good handover in terms of the structure and content;
- Uncertainty about when and to whom a handover should be provided;
- A lack of opportunities to develop and rehearse this specific skill;
- A sense of feeling ill-equipped or a lack of personal responsibility for providing handover proficiently;
- The danger of observing less desirable handover practices of others and assuming that this was the norm and of an acceptable standard;
- Lack of confidence or assertiveness to personally apply handover skills with the aid of a supportive mentor in practice.
Handover simulation pilot
Using the key themes from the audit, we then developed a pilot simulation experience to enable students to learn and rehearse handover skills within a safe and supportive environment within the university’s clinical skills suites.
Structuring the handover
To structure the handover, the students were taught to use a handover framework based on the SBAR approach for enhancing communication (NHS Institute for Innovation and Improvement, 2008).
This easy-to-remember tool aims to help both the person giving and the person receiving the handover to understand what information needs to be shared and the actions that need to be taken; this is because any handover is ineffective unless the information being shared is acted on.
The SBAR framework has four stages - situation, background, assessment and recommendation (Box 1). Prompts may vary between organisations and areas of practice, or because the purpose of hand-overs may differ. However, the person giving the handover must take care to keep to the objectives of the framework, without deviating or giving excessive and/or inappropriate information, as this may cause the handover to become fragmented or overloaded with too much information.
Box 1. SBAR approach to handover
- Identify yourself – this should include the site or unit you are calling from if you are communicating via telephone, or your name and job title if face to face
- Identify the patient by name and the reason for your handover
- Describe your concern
- Give the patient’s reason for admission
- Explain any significant medical history
- Give any patient background, such as diagnosis on admission, date of admission, any procedures undertaken, current medications, allergies, pertinent laboratory other diagnostic results
- Give current vital signs
- Explain any patient-specific supplementary assessment issues or risk indicators
- Describe clinical impressions and concerns
- Explain what you need if you are recommending that something needs to be done – be specific about the request and time frame
- Make suggestions
- Clarify expectations, such as what is going to happen next, when and who will do it
Adapted from NHS Institute for Innovation and Improvement (2008)
Simulation handover exercise
The simulation exercise was piloted with students at the end of their second year, who were selected because they had more exposure to practice placement areas than students in the lower years. They had also observed or participated in handovers in different settings and carried out for a range of purposes.
The simulation handover exercise had seven steps (Fig 1):
- Principles: students were given an overview of the need for effective handovers, the settings and instances in which they can occur and an introduction to the SBAR framework;
- Scenario: based on previous placement experience, students were asked to develop their own patient handover scenario, maintaining patient confidentiality. This gave the students personal ownership and helped them to transfer what they had learnt in the simulation to their own practice;
- Without SBAR: initially, students were asked to simulate a handover to a small number of peers using techniques they had previously observed or used. The aim of this stage was to give the students an opportunity to explore their existing cognitive and communication skills;
- With SBAR: the students were then asked to repeat the simulation exercise, but this time using the framework of the SBAR approach and guidance prompts;
- Peer feedback: after the two handovers, students were given feedback by the receivers of the handover and other students who had been non-participant observers. This was an opportunity for good practice to be highlighted and for areas for improvement to be identified.
- Personal reflection: in this stage of the simulation, students reflected on their own performance in giving the handover, the application of the SBAR tool and their response to peer feedback;
- Action planning: the final phase of the simulation gave students the opportunity to plan their personal development needs in relation to handovers and think about how they could transfer and apply this new learning into their own practice.
After the pilot, another feedback audit was carried out with the students who took part in the simulation. This appeared to show that this form and structure of simulating handover assists in developing nursing students’ communication skills. Comments included:
“I have learnt what information is appropriate to include in a handover.”
“I felt nervous but this has given me confidence to try this handover approach on placements.”
“I have learnt and understood the key concepts of handover and realised how easily mistakes can be made.”
“I will now take part in more handovers in practice with the support of my mentor.”
“This approach can be used in lots of different settings, both within the hospital and community settings…. I’m going to share this with my mentor.”
The next steps in developing handover confidence, competence and coordination among student nurses at the University of Derby is to embed the use of handovers in every simulation experience across the pre-registration nursing programme.
In addition, practice partners are involved in simulation activities, and mentors are being encouraged to support student nurses in applying their developing handover skills in practice.
Effective simulated and in-practice handover should not be isolated to one professional group. A further initiative is to explore opportunities for interprofessional simulation exercises using the SBAR approach. Allowing student nurses to take responsibility for improving the quality of their handovers will improve continuity of care, patient safety and outcomes.
- Ineffective handover can compromise patient safety
- Developing communication skills is a key domain of pre-registration nurse training standards
- Some student nurses are unsure what constitutes an effective handover or lack the confidence to deliver one
- The SBAR approach to handovers helps professionals to structure the information given
- Practising handovers in a safe environment helps build students’ knowledge and confidence
British Medical Association (2004) Safe Handover: Safe Patients. Guidance on Clinical Handover for Clinicians and Managers. London: BMA.
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: the Stationery Office.
NHS Institute for Innovation and Improvement (2008) Quality and Service Improvement Tools: SBAR.
Nursing and Midwifery Council (2010) Standards for Pre-registration Nurse Education. London: NMC.
Wong MC, Yee KC, Turner P (2008) Clinical Handover Literature Review. Tasmania: eHealth Services Research Group, University of Tasmania.
World Health Organization (2007) Collaborating Centre for Patient Safety Solutions. Communication During Patient Hand-overs: Patient Safety Solutions. Geneva: WHO.