Research Article
Perceptions of Barriers to Effective Surgical Handover: A Multi-Disciplinary Survey
Kavanagh DO1*, Sanfey HA2, Harrington C3 and Dozois EJ4
1Department of Surgery, Tallaght Hospital, Ireland
2Department of Surgery, South Illinois University, USA
3Department of Surgical Affairs, RCSI, Ireland
4Dept of CRS, Mayo Clinic, USA
*Corresponding author: Dara O Kavanagh, Dept of Surgery, Tallaght Hospital, Dublin 24, Ireland
Published: 30 Sep, 2016
Cite this article as: Kavanagh DO, Sanfey HA, Harrington
C, Dozois EJ. Perceptions of Barriers
to Effective Surgical Handover: A Multi-
Disciplinary Survey. Clin Surg. 2016; 1:
1146.
Abstract
Objective: We aimed to examine perceptions of barriers to effective surgical handover among
Healthcare professionals at Department of Surgery, Mayo Clinic, Rochester.
Methods: In 2012 healthcare providers across 10 surgical specialties were surveyed.
Results: The overall response rate was 48%. 96% agreed that it is an important component of patient
care while 74% agreed that an electronic handover tool should be available. There was a significant
difference in the views with respect to the need for an electronic handover tool (MLPs vs. residents:
85% vs. 63%: p=0.01). 62% of staff strongly agreed that education is necessary compared to 26%
of residents (p=0.0007). 75% of respondents agreed that time constraints is a relevant barrier
(p=0.091). 76% of respondents felt that a standardized process could be designed for use across the
entire Department of Surgery.
Conclusion: It is evident that a module of education and training followed by establishment of a
process of handover with standardized structure and content will allow the authors to establish a
purpose-built system to optimize surgical handover and improve patient safety.
Keywords: Surgical Handover; Barriers; Surgery
Introduction
The enactment of resident duty hour restrictions by the Accreditation Council on Graduate
Medical Education (ACGME) in 2003 in the United States was part of a global move to reduce the
workload of doctors in training [1]. A consistent body of evidence confirmed that existing work
practices were unsafe for the care giver (doctor) and the care recipient (patient). The aim of this
international legislation concerning duty hour restrictions was to promote patient safety and preserve
the well-being of the doctor. These restrictions have produced unanticipated novel challenges.
These include shift-work mentality, night-float systems, fragmentation of healthcare provision, and
abolition of apprentice-model of training and surgical handover [2-4]. The transmission of patient
information and responsibility (handover) is a pervading problem. Kitch et al. [5] reported that 59%
of residents report at least one sentinel event based on problematic handover during their previous
rotation. Further ACGME duty hour restrictions became effective in July 2011 while the European
Working Time Directive (EWTD) as being implemented throughout Europe with variable intensity
[6].
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reported on
15 years of sentinel events incorporating 6244 events. 91% of these were due to communication
errors. There are many other survey-based descriptive datasets confirming the magnitude of this
issue. Handover create an opportunity for error because the process is often characterized by
missing, inaccessible or forgotten information. Clinicians often fail to allocate enough time to
transfer patient data appropriately. Consequently recipients may not get a full, accurate picture of
the patients’ condition which leads to adverse outcomes. Arora et al. [7] highlighted that handover
communications are affected by content omission related to medications, investigations, consults or
active medical problems. Failure-prone communications are largely attributable to lack of face-toface
communication, double sign-outs and illegible/incomprehensible medical notes.
Using the example of an elective laparoscopic sigmoid colectomy
within an enhanced recovery program the average length of stay
would be 5 days. It is estimated that this inpatient stay will involve
a minimum of 15 resident handover to comply with duty hour
restrictions. This has resulted in the requirement of multiple care
handovers within a 24-hour period which may translate into loss
of continuity of care. The gap in care provision in North America
is supplemented by hospitalists who provide patient care within a
timeframe which will overlap resident shift changes. Apart from
the perceived threat to patient safety other consequences of an
ineffective handover include delays in treatment and ordering of
tests, incongruence in patient data and increased length of stay.
Key strategies have been proposed to overcome these perceived
barriers to effective handover. These include standardization of
the tool and process, use of communication mnemonics including
SBAR (Situation, Background, Assessment and Recommendation)
and incorporation of dedicated education sessions to provide better
training. It is well recognized that the ideal model of handover is faceto-
face facilitated by electronic patient data. Similarly, a dedicated
location is necessary which all members of the multidisciplinary team
can access to discuss/identify core components of patient care and
have an electronically accessible framework encompassing the relevant
information bundles for all team members. It should be carried out
at designated time-points which are ‘protected’ from interruptions.
It should involve the most senior departing care giver and the
oncoming care provider. It should include information relevant to
the patient’s likely clinical progress over the subsequent shift without
being exhaustive. It should be delivered in an environment conducive
to questioning and comprehension.
Although prior research provides a strong foundation to
understanding the problems associated with the handover
communication there is a paucity of literature on the nature of these
barriers. It is difficult to develop strategies to improve a situation
when the key components of the problem are not fully understood.
We, like others, have recognized a gap in the medical literature and
also in our own clinical practice in the area of surgical handover.
In recognizing the threat of inadequate handover to patient safety
we embarked on a process of standardizing and optimizing patient
handover at our institution. As we embarked upon a departmental
practice initiative to implement clear process guidelines for surgical
handover we evaluated the perception of the stakeholders to
determine what were the specific barriers to effective handover that
existed in the institution. The data acquired will be used to guide our
process development.
Table 1
Methods
Study design
This observational study involved a web-based survey with a
series of open and closed questions to identify the barriers to effective
handovers as perceived by all members of clinical care provision in
the Department. The study was approved by the institutional review
board (IRB).
Study setting and population
This research was conducted at the Mayo Clinic (Rochester,
Minnesota). The research was conducted in conjunction with
the Surgical Education Research Fellowship (SERF) linked to the
Association of Surgical Education (ASE). All residents, staff surgeons
and midlevel providers within the Department of Surgery were
invited to participate in an online survey. An email link to a structured
survey was sent with a cover letter emphasizing the magnitude of
this challenge to patient safety. The survey consisted of numerous
questions structured in the following categories: participant
demographics, handover tool, handover process and compliance with
the process of handover. The surveys were customized to each group
and included Likert-scaled questions, some simple yes/no answers
and open-ended questions. The Web-based survey was assessed by
healthcare researchers experienced in survey design and piloted
on a focus group of surgical residents, staff surgeons and midlevel
providers to ensure comprehension of the purpose of the survey,
language, clarity of the questions and ease of use. Answers were
assessed to ensure that the design would correctly address the key
question being posed. An initial cover letter was sent to all potential
participants 2 weeks prior to release of the survey detailing the date of
release and the importance of this survey. The survey was accessible
from September 15th until October 29th, 2012. E-mail reminders were
sent to all participants after 2 weeks emphasizing the importance of
the topic and how the responses may shape the future of surgical
handover at this institution. An additional web-link was sent to all
potential participants.
Data analysis
Information was collated into an anonymous database. Statistical
differences between the 3 groups studied were assessed using Chisquared
analysis. P values ≥0.05 were considered not significant.
Table 2
Results
The overall survey response rate was 179/370 (48%). This surveyed
population consisted of (number): midlevel providers/hospitalists
(94), staff surgeons (113) and residents (162). The response rate for
midlevel providers (MLPs), staff and residents was 59%, 48% and
43% respectively. Characteristics of the respondents are illustrated
in Table 1. When asked a series of closed questions about surgical
handover 96% agreed that it is an important component of patient
care, 74% agreed that an electronic handover tool should be available
to facilitate effective handover and 68% agreed that there should be
a designated time and place for handover. There was a significant
difference in the views of MLPs and residents with respect to the
need for an electronic handover tool (MLPs vs. residents: 85% vs.
63%: p=0.01). 47% of those who responded claimed that an electronic
handover tool existed in their department while 38% said there was
no existing system and 15% did not know. There was a significant
difference of opinion regarding the need for formal education and
training in surgical handover. 62% of staff surgeons strongly agreed
that it was necessary compared to 26% of residents (p=0.0007) (Table
2).
Barriers to handover
25% of staff surgeons strongly agreed that the absence of a
dedicated electronic tool was one of the most relevant barriers to
surgical handover. 11% of MLPS and residents felt that it was the most
relevant (p=0.014). Similarly 32% of staff surgeons felt the absence of a
standardized process was very relevant compared to 21% of residents
(p=0.015). Overall, 75% of respondents agreed that time constraints
is a relevant barrier and this did not vary between differing groups
(p=0.091). Unwillingness among staff surgeons to release residents
from clinical duties to perform handover was perceived as a very
relevant barrier in only 12% with no significant differences between
the groups (p=0.1) (Table 3).
Handover process
55% of staff surgeons considered 3 surgical handovers as ‘too
many’ in terms of patient safety risk. Similarly 53% of residents felt
this was excessive. Conversely significantly less MLPS considered
3 handovers excessive (p=0.001). There was concordance among
participants in 64% that surgical handover should not include
bedside rounds. There was a significant difference in the perceptions
of respondents regarding the role of telephone communication in the
process. 37% of staff felt this was the optimal mode and they also reiterated
their views in some of the comments illustrated in Table 3.
16% of residents felt that this was an optimal mode of communication
(p=0.02). 82% of respondents felt that e-mail was not the optimal
mode of communication and there was concordance between the
three groups. 46% of respondents felt that an electronic-based tool is
one of the optimal modes of communication (p=0.45). Two-thirds of
respondents favored a problem-based list rather than a system-based
comprehensive description of each patient. 73% felt this should be a
checklist tailored to the specialty rather than a system-based checklist.
80% felt that it should be held in a designated office with access to
information technology (IT) facilities. The majority of respondents
(>80%) felt that handover should include only residents and MLPs
or residents in isolation.76% of respondents felt that a standardized
process could be designed for use across the different specialties
within the Department of Surgery (Appendix 1) (Table 4 & 5).
Assessing compliance and quality of handover
24% of respondents felt that an independent observer in the
room is the optimal way to monitor compliance. 93% had no other
recommendations regarding compliance and the selected comments
were not in favor of monitoring compliance.
Table 3
Table 3
On a scale of 1 to 5, please indicate the relevance of the following barriers to an effective surgical handoff with 1 being the ‘least relevant’ and 5 being the
‘most relevant’.
Table 4
Table 5
Discussion
Patient safety is central to good surgical practice. Variables that
can impact upon this are extremely important. A global drive to
reduce duty hours for doctors in training has revealed the ability of a
poorly performed surgical handover to adversely impact upon patient
safety. In the current study there was often a divergence of opinion
regarding key components of surgical handover among staff surgeons,
MLPs and residents. The study clearly demonstrates that education
and formal training is very important, an electronic handover tool
should replace e-mail communications, a task-oriented checklist is
preferable to a system-based approach and handover compliance is
not something that should be monitored.
Standardization of the information content and process is
important for effective communication during handovers [8]. This
can be achieved by defining all components and providing appropriate
educational opportunities to reinforce the preferred format. In the
current study there was a large divergence of opinions in regard to
the perceived value of education and standardization of the process
using an electronic handover tool. When asked if ‘there should be
formal education’ 62% of staff surgeons strongly agreed regarding it’s’
importance compared to 26% of residents. Individual comments from
residents (not included) suggested a perceived increase workload
relating to additional educational online modules at the beginning
of each rotation. In fact, by standardising the process across the
department of surgery a single module of education would provide
appropriate training for the entire 5-year residency program. 74% of
respondents felt an electronic handover tool should be available to
facilitate communication. However, there was a significant divergence
of opinions among the different categories of respondents (staff vs.
MLPs vs. Residents =78% vs. 85% vs. 63%: p< 0.01). Lessons from
industry have provided valuable insights into how we can improve
patient safety [9]. In the medical literature there is ongoing debate
regarding the merits of standardizing communication behavior. It
allows clear and concise information sharing prompting delivery of
relevant and pertinent facts.
Despite 95% of respondents acknowledging that a ‘well-executed
surgical handover is an important component of patient care’ 1 in
6 respondents did not know if there was a designated handover
system within their own department. There is a paucity of literature
on perceived barriers to handover. Some would argue that in
designing a handover process one is implementing a strategy to
surmount existing barriers. Hence strategies such as standardizing
the information transferred, ensuring up-to-date information,
limiting interruptions and ensuring a structured face-to-face verbal
interchange has been proposed [10]. By evaluating the perceptions of
future stakeholders regarding barriers to handover we have identified
that time constraints is perceived as one of the key barriers by 75% of
respondents. 40% of respondents felt that there was a lack of awareness
of its importance. Interestingly over half of the respondents felt that
the additional clerical workload was a barrier with similar agreement
among all categories of respondents (p=0.08). Additionally, there is
a divergence of opinion regarding the lack of a standardized process
and formalized education among respondents. While over 60% of
staff surgeons consider both as major barriers 30-44% of residents
perceive these as major barriers. At the inception of the study one
may assume that residents may perceive the unwillingness of staff
surgeons to excuse them from clinical duties as a major barrier. In
fact only 1 in 5 residents and MLPs considered this a major barrier
and over 50% disagreed that it was a barrier at all.
Conversely, 32% of staff surgeons felt it was a barrier which
suggests unwillingness on the part of 1 in 3 staff surgeons to liberate
their resident from clinical duties to perform a surgical handover.
These findings have important implications for designing a future
process. By raising awareness of its importance through education
and selecting dedicated time slots surgical handover may be effectively
carried out facilitated by an electronic handover tool.
One can see from the selected comments that opponents to a
standardized process among residents and MLPs voice concerns
regarding increasing workload (electronic tool requiring regular
updating) while opponents among staff surgeons are more concerned
about the prospect of trainees having other clinical commitments
which will limit their availability for handover (Table 5). This may
reflect the fact that staff surgeons are not directly affected by the
increasing workload burden attached to a designated surgical
handover. However, these individual comments are not evident in an
overall analysis (Table 3). Kurt lewin described opposing institutional
forces that exist when change occurs in an institution. Resisting forces
will exist mainly from those who are affected most by the change
while those unaffected by the change will not object so intensively.
Previous work at University of California, San Francisco
demonstrated that compliance with duty hour restrictions requires
15 handovers per patients in a 5-day hospitalization or 3 per 24-hour
period. Over 50% of staff and residents perceived this as too many
in terms of patient safety. Having demonstrated elsewhere that this
is the requirement educationalists and patient safety enthusiasts
must define ways to minimize the risk to patient safety as surgical
handovers are inevitable going forward [11].
Although optimization of available information technology can
optimize surgical handover there is no substitute for face-to-face
verbal communication [12]. 82% of respondents agreed that e-mail
was not the optimal mode of communication in surgical handover
yet this is the standard medium of communication transfer in most
divisions at the time of writing. Clearly there is awareness by all that
face-to-face communication (74%) is the optimum modality. 55%
of MLPs feel that an electronic tool is an important component.
In clinical practice verbal communication would be supported
by some form of electronic copy to secure reproducibility and
minimize erroneous omission of key facts. As clinicians we cannot
rely on memory alone to transfer key patient information. 36%
of respondents felt that bedside rounds were not suited to surgical
handover. In practice this approach would not be practical or time
efficient. 37% of staff surgeons feel that phone communication is
adequate for a considerable portion. This may relate to the differences
in perceived content of the handover between staff and residents.
Staff surgeons may feel that the content of their handover could be
conveyed by phone, while residents could perceive a more complex
content which might not effectively be conveyed over the phone.
The authors contend that encouraging selective use of telephone and
face-to-face communications may nurture a culture of preferring a
telephone conversation for ease of completion of the handover rather
than for patient specific reasons.
Previous authors have suggested that a handover tool based on
the body-system format can be an effective strategy to address issues
with standardizing communication. This can reduce the variability of
handover in content and structure while providing a comprehensive
record of the patient [13]. In surgical units the higher patient volume
encountered in a handover combined with the limited impact of
surgery on specific systems may restrict the use of a system-based
approach. The current study consistently highlights among all
respondents that a handover structure based on current issues and
pending tasks would be preferable over a system-based checklist as
utilized in intensive care units. Furthermore, a standardized system
based on these broad categories could be applicable to the entire
Department of Surgery at the Mayo Clinic.
Our study has some important limitations. While the 48%
response rate is acceptable the attitudes of those who did not respond
may be different from those who did respond. Like many survey-based
studies ours lacked objective data to explain the group’s perceptions.
Despite these limitations we feel that the findings provide meaningful
perspectives which will strongly influence how we design and
implement a handover strategy at our institution.
In conclusion the current study has provided invaluable
information for the study group to prospectively design a process of
handover encompassing the views of all stakeholders. It is evident
that a module of education and training followed by establishing a
process of handover with standardized structure and content will
allow the authors to establish a purpose-built system to optimize
surgical handover and improve patient safety. Through ongoing
evaluation and feedback from the stakeholders we will continue to
develop and refine this model to meet the requirements of changing
work practices and patients perceptions.
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