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International Journal of Mental Health Nursing (2015) 24, 193–202
doi: 10.1111/inm.12102
Feature Article
Handover of patient information from the crisis assessment and treatment team to the inpatient psychiatric unit Amanda Waters,1 Natisha Sands,2 Sandra Keppich-Arnold3 and Kathryn Henderson3 1
School of Nursing and Midwifery, Deakin University, Melbourne, 2School of Nursing and Midwifery, Deakin University, Geelong, and 3Alfred Psychiatry, Alfred Health, Melbourne, Victoria, Australia
ABSTRACT: Handover, or the communication of patient information between clinicians, is a fundamental component of health care. Psychiatric settings are dynamic environments relying on timely and accurate communication to plan care and manage risk. Crisis assessment and treatment teams are the primary interface between community and mental health services in many Australian and international health services, facilitating access to assessment, treatment, and admission to hospital. No previous research has investigated the handover between crisis assessment and treatment teams and inpatient psychiatric units, despite the importance of handover to care planning. The aim of the present study was to identify the nature and types of information transferred during these handovers, and to explore how these guides initial care planning. An observational, exploratory study design was used. A 20-item handover observation tool was used to observe 19 occasions of handover. A prospective audit was undertaken on clinical documentation arising from the admission. Clinical information, including psychiatric history and mental state, were handed over consistently; however, information about consumer preferences was reported less consistently. The present study identified a lack of attention to consumer preferences at handover, despite the current focus on recovery-oriented models for mental health care, and the centrality of respecting consumer preferences within the recovery paradigm. KEY WORDS: crisis assessment treatment team, handover, inpatient psychiatric unit, mental health, nursing.
INTRODUCTION Handover is the transfer of verbal and written communication of patient information between members of the health-care team. It is integral to the practice of all healthcare clinicians (Millar & Sands 2012). The Australian Commission for Safety and Quality in Health Care
Correspondence: Amanda Waters, School of Nursing and Midwifery, Deakin University, 48 Harrison Avenue, Burwood, VIC 3125, Australia. Email: [email protected] Amanda Waters, RN, BN (Hons). Natisha Sands, RN, BN (Hons), PhD. Sandra Keppich-Arnold, RN, GDHE&P. Kathryn Henderson, RN, GDACN. Accepted August 2014.
© 2014 Australian College of Mental Health Nurses Inc.
(ACSQHC 2011) recognizes the importance of handover in the continuum of health care, and acknowledges that information transferred between clinicians during the handover can directly affect the quality of care delivered to patients. Poor-quality handover practice has been linked to a number of unfavourable patient outcomes, including increased hospital stays, consumer dissatisfaction, delays in treatment, and other adverse clinical outcomes (Hill & Nyce 2010; Manser & Foster 2011; Siemsen et al. 2012; World Health Organization Collaborating Centre for Patient Safety Solutions (WHOCCPSS) 2007). In the present study, we report on the findings of a study that investigated handover between the crisis assessment and treatment team (CATT) and the inpatient psychiatric unit (IPU).
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There is little in the published literature that reports on handover practices in acute psychiatric settings, and no previous research that has specifically investigated handover between the CATT and the IPU. The lack of studies in this area is concerning, given that in Australia and internationally, CATT service models are in wide use to facilitate community access to psychiatric assessment and care for people who are experiencing acute mental health crises and associated risks of harm (Cotton et al. 2007; Hasselberg et al. 2011a,b; Johnson 2013). The initial assessment information attained by CATT is critical to guiding safe, high-quality consumer care (Singh et al. 2012), yet little is known about what types of information are communicated by CATT to the IPU, the way in which this information is transferred, or how this is used to guide care planning and interventions in the IPU. The CATT provides services for people with mental illness who are in psychiatric crisis in the community (Carroll et al. 2001; Hasselberg et al. 2011a; Johnson 2013, 2004; Singh et al. 2012; Victorian Government 2007). Psychiatric crises are characterized by acute disturbances of mental state and behaviour, and are associated with significant risks (Oliva & Compton 2008). Consumers experiencing acute psychiatric crises in the community are a vulnerable group, requiring timely intervention to ensure appropriate management of risks and assertive treatment for their condition (Carroll et al. 2001; Singh et al. 2012; Victorian Government 2007). Safe, effective management of consumers transferred from the community to an IPU requires a specialized team of multidisciplinary mental health clinicians working collaboratively to ensure the consumer receives quality care in a safe environment (Cotton et al. 2007; Deacon et al. 2006; Jones 2006; Singh et al. 2012). New South Wales Health (NSW Health 2012) recognizes the transfer of consumers from the community to the IPU as a highrisk process, and developed a policy to inform this procedure. One of the major principles stipulated throughout this policy is the importance of accurate and timely handover communication, particularly the accurate transfer of risk information. Communication failures are one of the main reasons for the occurrence of sentinel events in health care (WHOCCPSS 2007). The current emphasis on holistic patient care has resulted in health-care settings evolving into dynamic, multifaceted environments, where entire teams of multidisciplinary clinicians are directly or indirectly involved with a patient’s care (Bowers et al. 2009; Deacon & Cleary 2012). The importance of effective communication in acute psychiatric settings cannot be understated; communication failures can lead to inad-
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equate treatment outcomes, but can also place clinicians at significant risk of assault and injury (Kuehn 2010). Consumers presenting in psychiatric crisis require care that is cognizant of their risks as a means of promoting consumer and clinician safety (Sands et al. 2012). In an observational study examining risk communication at handover on an IPU, Millar and Sands (2012) found that risk information was often inconsistently communicated. They emphasized the need for consistency and accuracy in the transfer of information during handover, noting the strong link to consumer and clinician safety, as well as more favourable care outcomes (Millar & Sands 2012). In a study examining care transfers from the emergency department to medical wards, Horwitz et al. (2009, p. 701) used the phrase ‘dropping the baton’ to describe breakdowns in communication between multiple stakeholders, adding that communication breakdowns can lead to significant treatment errors and care disruptions. Studies examining emergency patient transfers identify different communication styles between clinicians, poor retention of information, and multiple interruptions as contributing to poor-quality handover (Bost et al. 2012; Evans et al. 2010; Owen et al. 2009). A number of recent studies examining handover practices in a variety of generalist clinical settings have recommended the use of structured handover tools, such as ‘ISBAR’ (Identify, Situation, Background, Assessment and Recommendation) or ISOBAR (Identify, Situation, Observation, Background, Action, Response), in order to improve the quality and consistency of handover practice (Bost et al. 2012; Millar & Sands 2012; Owen et al. 2009; Quin et al. 2009; Yee et al. 2009). Very few studies have examined the use of structured handover tools in psychiatric settings (Hunt et al. 2012; Poh et al. 2013), or handover practices in specialized mental health settings, such as CATT. The primary aim and focus of the present study was to identify and articulate the types of information communicated in the CATT to IPU handover, and the practices and processes used in information transfer. A secondary aim of the study was to explore care planning and interventions arising directly from information transferred in the handover.
MATERIALS AND METHODS This study employed an exploratory, descriptive design using an observational method. Nineteen structured observations of CATT to IPU handover were undertaken. All clinical documentation related to the handover completed within 24 hours of the consumer’s admission was © 2014 Australian College of Mental Health Nurses Inc.
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audited prospectively for information relevant to the handover, and evidence of care planning and interventions arising directly from handover information.
Setting The study was conducted at a major tertiary referral hospital in metropolitan Melbourne, Australia. The observations of handover were undertaken on one IPU, which comprised of 22 low-dependency beds and six highdependency beds.
Participants The study involved observations of CATT and IPU staff undertaking handover. The CATT is comprised of nursing, medical, and allied health staff who provide community-based psychiatric assessment and early treatment. A multidisciplinary team of medical, nursing and allied health clinicians staffs the IPU. Information sessions were held for CATT and IPU staff to explain the purpose of the research project. An information flyer explaining the project was left onsite in the staff offices, along with packages containing the participant information and consent form, and instructions for returning signed consent forms.
Ethical considerations The hospital and university Human Research and Ethics Committee granted ethical approval to conduct the research. A waiver of consent was sought for the use of patient information for the purposes of the documentation audit, as per the National Statement on Ethical Conduct in Human Research (NHMRC 2007).
Instrumentation A handover observation tool (Millar & Sands 2012), developed in a previous study examining IPU handover, was adapted for use in this study. The tool includes sections to record handover information communicated verbally and in writing, and whether this information was transferred into the consumer’s medical records. Consistent with the original tool, items such as the consumer’s age, diagnosis, sex, risk history, risk management plan, and mental state, were included, and three additional items were added to record psychiatric history, social status, and care planning outcomes arising from the handover. A separate section was added to the handover observation tool to record qualitative field notes taken at the time of handover. The original tool was pilot tested by Millar and Sands (2012), and the modified version of the tool was tested again in this study on the first three handovers observed. The tool was determined to be appropriate for collecting the data for this project. © 2014 Australian College of Mental Health Nurses Inc.
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Data collection Data were collected between April 2013 and August 2013. At the commencement of each handover, the researcher first confirmed that clinicians involved in the handover had provided written consent to participate in the study. The researcher then observed the handover and recorded the observations into the data-collection tool. Following the observation of the handover, all related clinical documentation for the following 24 hours was reviewed to verify which information communicated at the handover had been documented in the patient records, and to identify any care planning or interventions arising from the handover. Qualitative field notes were also taken at the time of handover to document any information pertinent to the handover not captured by the handover observation tool; for example, interruptions and their impact on handover, the handover environment, and descriptions of the handover process.
Data analysis Standard descriptive statistical analysis was performed on the quantitative data to calculate frequencies and percentages. All qualitative field note data collected during the structured observations were analysed using content analysis method (Krippendorf 2004). Content analysis provides a structured framework for analysing qualitative data. Using this method, key words and phrases are systematically analysed (frequency, repetition) to identify patterns and reoccurring themes in the data (Hsieh & Shannon 2005). A second researcher was then used to verify the themes generated from this iterative process.
RESULTS Nineteen observations of the CATT to IPU handover were undertaken during the data-collection period from April to August 2013. A total of six CATT clinicians and 14 IPU staff participated in the study. All participants were registered or enrolled nurses with 3 months–30 years of clinical experience in psychiatry. Admissions were categorized according to which CATT service had initially assessed and admitted the consumer. The majority (63%, n = 12) of consumers were admitted via emergency department CATT (ECATT). The admissions were then further categorized into Section 9 involuntary admissions (recommended under the Victorian Mental Health Act 1986; Victorian Government 1986) and voluntary admissions. The
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A. WATERS ET AL. TABLE 1:
Summary of findings of the CATT–IPU handover and documentation file audit
Information type Admission type
Section 9 admissions Patient diagnosis
Patient sex Verbal handover
Clinical file audit
Care outcomes
Variable
n
Frequency (%)
ECATT CATT Section 9 admission Voluntary admission ECATT admission CATT admission Schizophrenia Bipolar affective disorder First-episode psychosis Depression Generalized anxiety disorder Borderline personality disorder Other (unclear diagnosis) Male Female Psychiatric history Risk history Mental state Social status Care instructions Patient preferences Risk assessment Admission entry INAT Power chart CATT paperwork Seclusion/restraints PRN medications LDU/HDU Patient preferences
12 7 13 6 10 3 6 1 5 2 1 3 1 10 9 19 16 19 16 19 10 18 18 18 19 18 2 15 16 10
63 37 68 32 77 23 32 5 26 11 5 16 5 53 47 100 84 100 84 100 53 95 95 95 100 95 11 79 84 53
CATT, crisis assessment and treatment teams; ECATT, emergency crisis assessment and treatment teams; HDU, high-dependency unit; INAT, initial nursing assessment tool; IPU, inpatient psychiatric unit; LDU, low-dependency unit; PRN, pro re nata.
majority of consumers were admitted as involuntary patients under Section 9. ECATT admitted 77% (n = 10) of involuntary patients, as compared to CATT who admitted 23% (n = 3) of involuntary patients. Basic demographic data were collected on the consumer population. A summary of findings of the CATT to IPU handover is reported in Table 1. There were close to equal numbers of males 53% (n = 10) and females 47% (n = 9) admitted during the data-collection period. The consumers’ ages ranged from 18 years to 46 years, with the majority of consumers in the 35–44-year age range. While a variety of different psychiatric diagnoses were identified within the consumer population, the most common diagnosis was schizophrenia (32%, n = 6), followed by first-episode psychosis (26%, n = 5) and borderline personality disorder (16%, n = 3).
Content of verbal handover The results showed that the consumers’ psychiatric history (100%, n = 19), mental state (100%, n = 19), and care instructions (100%, n = 19) were consistently communicated during each occasion of handover. The consumers’ risk history and social status were mostly communicated during handovers (84%, n = 16). Consumer preferences were less frequently communicated in 53% (n = 10) of handovers.
Handover documentation audit Following the observation of handover, all clinical documentation produced within 24 hours of admission was reviewed to verify the types of information transferred from handover to patient medical records. Five types of documentation suites were identified as containing © 2014 Australian College of Mental Health Nurses Inc.
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information reported at handover; the risk-assessment document; the Initial Nursing Assessment Tool (INAT), which is the main tool used for formulating an initial nursing care plan and includes the consumer’s contacts details, community supports, and care preferences; the nursing admission notes; the CATT documentation and ‘power chart’; the electronic health record; and the database for clinical documentation accessible to all staff within the health service. The results of the documentation audit indicated consistent transferal of verbal handover information to the clinical documentation, and high levels of adherence with documentation. Consumer preferences are entered in the nursing admission file entry, as well as in the INAT. The INAT was considered complete if all documentation had been completed and an initial nursing care plan had been formulated within 24 hours of admission. The audit indicated that in almost half of the admissions (42%, n = 8), the section specifying the consumers’ preferences for care was left blank or incomplete.
Care-planning outcomes The most common care outcomes arising directly from the handover were the designation of low-dependency units (LDU)/high-dependency units (HDU) (84%, n = 16) and the administration of pro re nata (PRN) medications (79%, n = 15). Consumer preferences were facilitated in 53% (n = 10) of cases, and the use of seclusion or restraints arising from handover information was minimal (11%, n = 2).
Observations derived from qualitative field notes Field notes were taken at that time of the handover observation to describe events or issues that might have impacted on the conduct of the handover. Three important themes emerged from the content analysis of the field notes data: the handover environment, staffing profile, and the consideration of consumer preferences. The setting for handover was a medium-sized communal staff area with multiple access points. The handover room is enclosed on all sides by windows, giving a fish bowl-type effect. At any given time, the handover area could contain up to 20 nurses, doctors, allied health staff, and administration personnel in this confined space, with multiple conversations occurring simultaneously. The researcher observed that the room was extremely busy and crowded during nursing shift change (from the morning to the afternoon), where for approximately 2 hours, nursing staff numbers doubled. The following excerpt from the field notes reflects the challenges of © 2014 Australian College of Mental Health Nurses Inc.
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receiving handover within this setting during nursing shift changeover. Nursing shift change, many people in the room. AM staff is giving individual handovers to PM staff. There is nowhere for CATT to sit to give handover. Many conversations are taking place right now, very difficult to hear what is being said. The CATT clinician is speaking very quickly, the nurse is writing information down, but how much of it can they hear?
The most commonly-observed handover practice was for the CATT clinician to deliver handover to the IPU nurse in a continuous stream, without the use of a structured handover tool, such as the ISOBAR, to guide the conduct of the handover (Yee et al. 2009). The handover from CATT to the IPU nurse accepting the transfer of care was generally no more than 5 minutes from start to finish. However, prior to the CATT clinician’s arrival, the CATT had already provided a brief telephone handover to the nursing shift leader who would transcribe the information being transferred onto loose-leaf paper. The nursing shift leader would then provide a brief verbal handover and give the loose-leaf sheet to the nurse accepting the admission. These multiple points of communication meant that by the time the CATT clinician arrived with the incoming consumer, the nurse accepting the transfer of care usually had a reasonable second-hand account of what was to be expected during the handover. On several occasions, the consumers being admitted to the unit were well-known to staff. Handover for ‘wellknown’ patients was typically brief, and usually incorporated a reference to the clinicians’ familiarity with the consumer. There was an expectation from the clinician handing over that the consumer should be well-known, and therefore, little historical information was provided, as the following extract from the field notes illustrates: CATT clinician began handover by saying, ‘OK, introducing our good friend, Mr. X, very well-known to XXX Psych, we all know this young man. He left us 2 weeks ago, didn’t show up for his depot, and here we are!’.
The skill mix of clinicians working on the IPU was observed to be diverse; however, a significant proportion of the IPU nurses were observed to be junior staff working under the guidance and mentorship of senior staff. An important observation to arise from the study was that junior staff members were less likely to comment and ask CATT clinicians questions about the consumer during the handover than experienced staff. This was highlighted during one of the observations where the receiving nurse was very experienced and requested
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detailed consumer information in order to formulate a plan of care, as the following field note excerpt illustrates: The consumer is a high-aggression risk with a history of assault, and has been recommended for HDU. The nurse receiving handover is very experienced and asked many questions, such as ‘Does the consumer have a drug and alcohol history?’, ‘What sets this guy off?’, ‘Is there a history of mental illness in the family?’ The CATT clinician had to check the file several times to answer all his questions.
The participation of the nursing shift leader was also observed to be disruptive to the delivery of the handover. The nursing shift leader was subject to continuous interruptions, which resulted in a fragmented handover: The handover has been interrupted twice due to the shift leader being needed by ward staff and to speak to the bed manager on the phone. After the second interruption, the shift leader didn’t return, and the CATT clinician said they didn’t have time to wait around, plus the consumer was agitated and needed medication, so they just kept going.
Consumer preferences As previously noted, consumer preferences were communicated by the CATT to the IPU staff in approximately half of the handovers observed. The consumer preferences most frequently transferred at handover included requests for particular foods, telephone access to call family members, and requests for a single room versus a shared room. The following field note excerpt describes an occasion of handover where consumer preferences were transferred: Male consumer received under Section 9, no fixed address. He has no family or community supports, identifies a pigeon as being his only friend. He was happy to come into hospital until the CATT clinician opened up his suitcase and saw that he had packed a decomposing pigeon that had died earlier in the week. The CATT clinician told him that he would need to dispose of the pigeon, at which point the consumer became distressed and refused to be admitted. The CATT then agreed that the consumer could bring the pigeon to hospital and bury it in the ward’s courtyard, which the consumer agreed to.
The information about the pigeon was communicated verbally to IPU staff, recorded in the documentation, and this consumer preference was acted on according to the agreement made with the consumer.
DISCUSSION The present study found that neither CATT nor IPU staff utilized structured handover tools when delivering
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or receiving handover, despite the hospital guidelines for handover practice stipulating the use of ISBAR for handover. Although CATT and IPU clinicians were not observed to use handover tools, certain information types were consistently transferred across all of the handovers observed. Key clinical information, such as the consumer’s psychiatric history, mental state, risk history, social status, and care instructions, was consistently communicated at handover. Contrary to these findings, Millar and Sands’s (2012) study found that the risk information was communicated inconsistently, especially during the handover of consumers deemed to be ‘high-risk’ consumers. It is difficult to compare these findings in any meaningful way, due to the small sample size of the present study and the highly specific nature of the CATT to IPU handover, as compared to the routine shift-to-shift handover examined in Millar and Sands’s (2012) study. Consumer preferences were only reported in 53% of handovers in this study, despite clear expectations from the health organization for this to be completed in the INAT. Respecting consumer preferences and choices is a key theme of current Australian safety and quality literature (ACSQHC 2011), and this worldview is articulated in Standard 3 of the National Standards for Mental Health Services, Consumer and Carer Participation (Australian Government 2010). The notion of ‘consumer participation’ exemplifies person-centred care, where the needs, wishes, and goals of the person/consumer are used to tailor individualized care that addresses the holistic and unique needs of the consumer (Australian Government 2010; Fisher & Happell 2009; Frese III et al. 2001). Person-centred approaches to consumer care are also consistent with recovery-focused approaches to mental health care, which highlight the importance of being guided by consumer preferences, goals, and hopes in care planning (Fisher & Happell 2009). In the new paradigm of recovery-focused mental health care, a potential solution to the failure to adequately report consumer preferences at handover might be to actively involve consumers in the handover. This approach is also consistent with Standard 6 of the Handover Safety and Quality Improvement Guide, which states that the effectiveness of handover can be improved with active consumer participation (ACSQHC 2012). To date, no research has investigated the active participation of mental health consumers in handover. A factor that might have impacted on the consistency of reporting of consumer preferences was the acuity of consumers being handed over. It is possible that the consumers handed over in the present study were © 2014 Australian College of Mental Health Nurses Inc.
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unable to articulate their preferences for care as a result of being acutely unwell. In a study investigating serviceuser perceptions of telephone-based mental health triage, Elsom et al. (2013) found low levels of serviceusers’ involvement in decision-making, and that few service-users reported being asked about their preferences. Elsom et al. (2013) observed variations in the extent to which consumers in crisis want to, or feel able to, be involved in their care when experiencing psychiatric crisis. Scheyett et al. (2007) observed that during times of psychiatric crisis, consumers receiving treatment can experience a loss of autonomy and choices, resulting in potentially traumatic experiences and a reluctance to engage in future treatment. Tanenbaum (2008) found that consumers with mental illness value having a range of different treatment choices presented to them, and that the effectiveness of evidence-based interventions sometimes mattered less than being offered a choice. Fisher and Happell (2009, p. 182) echo this by stating: ‘If evidence-based practice does not take account of the human aspect of treatment, then it is not genuine recovery-oriented treatment’. Observations of handover in this study suggest that familiarity with the consumer might influence the duration and quality of the handover, a theme echoed in a study examining the practices of handover in a psychiatric rehabilitation setting (McCloughen et al. 2008). The handover of frequent service-users requires the same amount of attention to detail as the handover of new consumers; all consumer information should be updated regularly, and mental state and risk level should be reassessed on admission and thoroughly communicated at handover (McCloughen et al. 2008; Millar & Sands 2012). The most common care planning outcomes arising from handover identified in the present study were decisions to admit the consumer to LDU or HDU, and decisions to administer PRN medications. It was observed that immediate care decisions were frequently made during the initial telephone handover from CATT to the shift leader prior to the consumer’s arrival. These findings confirm that important care decisions typically arise from handover, and highlight the need for accuratelytransferred clinical information. The present study found that IPU clinicians are required to make rapid decisions about care based on the information provided to them in a brief CATT handover, and this reaffirms the need for effective and accurate communication at handover to facilitate safe, appropriate care (Fairbanks et al. 2007; Trenoweth 2003). © 2014 Australian College of Mental Health Nurses Inc.
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Transfer of care from community to inpatient settings Transfers of care from the community to the IPU were observed to involve several points of contact and types of communication to facilitate the process. Fairbanks et al.’s (2007) study revealed the complexity associated with multiple points of communication in emergency patient transfer, and identified care transfers as a patient safety issue. Mental health-care transfers are particularly complex (NSW Health 2012). A key recommendation of Millar and Sands’s (2012) study was the development of a structured handover tool that adequately captures specific risk information for use in acute psychiatric settings. Further research examining the CATT to IPU transfer and handover processes is required to determine the specific information requirements for the purpose of care transfers from the community to the IPU. The handover environment in this study was observed to be ‘busy’, and at times chaotic, with staff coming and going and multiple interruptions. Bost et al. (2012) reported similar findings in a study examining emergency department handover, where the chaotic and loud atmosphere presented several barriers to the paramedics delivering effective handover to emergency department staff. Participants were observed to have to repeat the content of handover several times to different clinicians, resulting in inconsistent information transferal (Bost et al. 2012). Interestingly, the present study found that in spite of the busy, noisy handover environment, there was a high level of consistency in the transfer of clinical information. An important insight gained from the present study was the potential impact of staff skill mix on the quality of handover, and the value of having experienced IPU staff present during the handover. Senior IPU staff participated actively in the handover and asked questions relating to the consumers’ care requirements, as compared to junior staff, who were passive recipients of the handover. Schwartz et al.’s (2011) study showed that junior nurses typically adopt a passive role to ‘fit in’. A more structured approach to handover that includes minimum standards for information exchange might facilitate more active participation in handover by staff at every skill level.
Implications for practice Acute inpatient settings have been criticized in recent literature for a perceived lack of consultation with consumers about their care (Fisher & Happell 2009; Frese III et al. 2001; Walsh & Boyle 2009) and lack of involvement in decision-making (Bowers et al. 2009). As mental health services move towards a more recovery-oriented approach (Australian Government 2009; Australian
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Government 2010), considering and communicating consumer preferences will become the expected standard in psychiatric settings (Australian Government 2009). The new Victorian Mental Health Act (2014) stipulates the importance of involving consumers in decisions about their care, and respecting consumer choices and preferences, as the following quote illustrates: ‘Persons receiving mental health services should be involved in all decisions about their assessment, treatment and recovery and should be supported to make, or participate in, those decisions and their views and preferences should be respected’ (Victorian Government 2014, p. 2). Consumer advocates also argue that greater emphasis should be given to ensuring that the consumer’s preferences are considered wherever possible to promote collaborative engagement (Fisher & Happell 2009). Within a largely-restrictive setting, such as an IPU, the consideration of care preferences via collaborative engagement with consumers can lead to improved service-user experience (Walsh & Boyle 2009). This study raises the question of how best to promote the inclusion of the consumer preferences in the delivery of handover in acute psychiatric settings. This study has a number of limitations. First, the generalizability of the study is limited due to the small sample size and the fact that it was a single-site study. A limited number of CATT clinicians participated in the handover, and therefore, it is difficult to determine with any accuracy how representative the practices observed in this study are of CATT handover practice. Second, a single researcher undertook the observations; the participation of other researchers in the data collection might have yielded different perspectives on handover. Nurses dominated the sample of clinicians in the study, even though CATT and IPU roles are multidisciplinary. Finally, it is possible that clinician practice was influenced by the presence of the researcher observing handover, and the impact this might have had on the study findings is unknown. The strengths of the study lie in its original contribution to the foundational body of knowledge on the CATT to IPU handover. Additionally, the use of a published handover observational tool for data collection and the prospective observational design were successful approaches that resulted in the study meeting its overall aims.
CONCLUSION Mental health-care transfers from the community to inpatient units are particularly complex and require consistent and accurate communication of information. Handover
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serves as the vital link in facilitating safe continuity of care, yet in spite of its importance to safety and continuity of care, little is known about the practice of CATT to IPU handover. Multisite research using large samples is now needed to extend on these findings and identify the minimum requirements for safe, accurate CATT to IPU handover that is inclusive of consumer choices and preferences.
REFERENCES Australian Commission for Safety and Quality in Health Care (ACSQHC) (2011). External Evaluation of the National Clinical Handover Initiative Pilot Program. [Cited 8 October 2013.] Available from URL: http://www.safetyandquality .gov.au/wp-content/uploads/2012/02/National-ClinicalHandover-Initiative-Pilot-Program-Evaluation-FinalReport-Website-Ready-Version-February-20111.pdf Australian Commission for Safety and Quality in Health Care (ACSQHC) (2012). Standard 6: Clinical Handover. Safety and Quality Improvement Guide. [Cited 29 May 2014.] Available from URL: http://www.safetyandquality.gov.au/ wp-content/uploads/2012/10/Standard6_Oct_2012_WEB .pdf Australian Government (2009). Fourth national mental health plan: An agenda for collaborative government action in mental health 2009–2014. [Cited 20 August 2013.] Available from URL: http://www.health.gov.au/internet/publications/ publishing.nsf/Content/mental-pubs-f-plan09-toc Australian Government (2010). National standards for mental health services. [Cited 20 August 2013.] Available from URL: http://www.health.gov.au/internet/main/publishing.nsf/ Content/mental-pubs-n-servst10 Bost, N., Crilly, J., Patterson, E. & Chaboyer, W. (2012). Clinical handover of patients arriving by ambulance to a hospital emergency department: A qualitative study. International Emergency Nursing, 20 (3), 133–141. Bowers, L., Chaplin, R., Quirk, A. & Lelliott, P. (2009). A conceptual model of the aims and functions of acute inpatient psychiatry. Journal of Mental Health, 18 (4), 316–325. Carroll, A., Pickworth, J. & Protheroe, D. (2001). Service innovations: An Australian approach to community carethe Northern Crisis Assessment and Treatment Team. Psychiatric Bulletin, 25, 439–441. Cotton, M.-A., Johnson, S., Bindman, J. et al. (2007). An investigation of factors associated with psychiatric hospital admission despite the presence of crisis resolution teams. Biomed Central Psychiatry, 7 (52), 1–11. Deacon, M. & Cleary, M. (2012). The reality of teamwork in an acute mental health ward. Perspectives in Psychiatric Care, 49 (1), 50–57. Deacon, M., Warne, T. & McAndrew, S. (2006). Closeness, chaos and crisis: The attractions of working in acute mental © 2014 Australian College of Mental Health Nurses Inc.
HANDOVER OF PATIENT INFORMATION health care. Journal of Psychiatric and Mental Health Nursing, 13 (6), 750–757. Elsom, S., Sands, N., Roper, C., Hoppner, C. & Gerdtz, M. (2013). Telephone survey of service-user experiences of a telephone-based mental health triage service. International Journal of Mental Health Nursing, 22 (5), 437–443. Evans, S. M., Murray, A., Patrick, I., Fitzgerald, M., Smith, S. & Cameron, P. (2010). Clinical handover in the trauma setting: A qualitative study of paramedics and trauma team members. Quality & Safety in Health Care, 19 (6), 1–6. Fairbanks, R. J., Bisantz, A. M. & Sunm, M. (2007). Emergency department communication links and patterns. Annals of Emergency Medicine, 50 (4), 396–406. Fisher, J. E. & Happell, B. (2009). Implications of evidencebased practice for mental health nursing. International Journal of Mental Health Nursing, 18 (3), 179–185. Frese, F. J. III, Stanley, J., Kress, K. & Vogel-Scibilia, S. (2001). Integrating Evidence-Based Practices and the Recovery Model. Psychiatric Services, 52 (11), 1462–1468. Hasselberg, N., Grawe, R. W., Johnson, S. & Ruud, T. (2011a). An implementation study of the crisis resolution team model in Norway: Are the crisis resolution teams fulfilling their role? Biomed Central Health Services Research, 11 (96), 1–9. Hasselberg, N., Grawe, R. W., Johnson, S. & Ruud, T. (2011b). Treatment and outcomes of crisis resolution teams: A prospective multicenter study. Biomed Central Psychiatry, 11 (183), 1–11. Hill, W. & Nyce, J. (2010). Human factors in clinical shift handover communication: Review of reliability and resilience principles applied to change of shift report. Canadian Journal of Respiratory Therapy, 46 (1), 44–51. Horwitz, L. I., Meredith, T., Schuur, J. D., Shah, N. R., Kulkarni, R. G. & Jenq, G. Y. (2009). Dropping the baton: A qualitative analysis of failures during the transition from emergency department to inpatient care. Annals of Emergency Medicine, 53 (6), 701–710. Hsieh, H. F. & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15 (9), 1277–1288. Hunt, G. E., Marsden, R. & O’Connor, N. (2012). Clinical handover in acute psychiatric and community mental health settings. Journal of Psychiatric and Mental Health Nursing, 19 (4), 310–318. Johnson, S. (2004). Crisis resolution and intensive home treatment teams. Psychiatry, 3 (9), 22–25. Johnson, S. (2013). Crisis resolution and home treatment teams: An evolving model. Advances in Psychiatric Treatment, 19, 115–123. Jones, A. (2006). Multidisciplinary team working: Collaboration and conflict. International Journal of Mental Health Nursing, 15 (1), 19–28. Krippendorf, K. (2004). Content Analysis: An Introduction to Its Methodology, 2nd edn. Thousand Oaks, CA: SAGE Publishing. © 2014 Australian College of Mental Health Nurses Inc.
201 Kuehn, B. M. (2010). Violence in health care settings on rise. Journal of the American Medical Association, 304 (5), 511– 512. Manser, T. & Foster, S. (2011). Effective handover communication: An overview of research and improvement efforts. Best Practice & Research Clinical Anaesthesiology, 25 (2), 181–191. McCloughen, A., O’Brien, L., Gillies, D. & McSherry, C. (2008). Nursing handover within mental health rehabilitation: An exploratory study of practice and perception. International Journal of Mental Health Nursing, 17 (4), 287–295. Millar, R. & Sands, N. (2012). ‘He did what? Well that wasn’t handed over?’ Communicating risk in mental health. Journal of Psychiatric and Mental Health Nursing, 20 (4), 345–354. National Health and Medical Research Council (NHMRC) (2007). National Statement on Ethical Conduct in Human Research. [Cited 20 August 2013.] Available from URL: http://www.nhmrc.gov.au/_files_nhmrc/publications/ attachments/e72.pdf New South Wales Health (NSW Health) (2012). Transfer of care from mental health inpatient services. [Cited 20 July 2013.] Available from URL: http://www0.health.nsw.gov.au/ policies/pd/2012/pdf/PD2012_060.pdf Oliva, J. R. & Compton, M. T. (2008). A statewide Crisis Intervention Team (CIT) initiative: Evolution of the Georgia CIT program. Journal of the American Academy of Psychiatry and the Law Online, 36 (1), 38–46. Owen, C., Hemmings, L. & Brown, T. (2009). Lost in translation: Maximizing handover effectiveness between paramedics and receiving staff in the emergency department. Emergency Medicine Australasia, 21 (2), 102–107. Poh, C. L., Parasuram, R. & Kannusamy, P. (2013). Nursing inter-shift handover process in mental health settings: A best practice implementation project. International Journal of Evidence-Based Healthcare, 11 (1), 26–32. Quin, D. M., Moulden, A. L., Fraser, S. H., Lee, O. K. E. & McGarrity, P. (2009). Evaluation of the acceptability of standardised clinical handover tools at four Victorian health services. Medical Journal of Australia, 190 (11), 141–143. Sands, N., Elsom, S., Gerdtz, M. & Khaw, D. (2012). Mental health-related risk factors for violence: Using the evidence to guide mental health triage decision making. Journal of Psychiatric and Mental Health Nursing, 19 (8), 690–701. Scheyett, A. M., Kim, M. M., Swanson, J. W. & Swartz, M. S. (2007). Psychiatric Advance Directives: A Tool for Consumer Empowerment and Recovery. Psychiatric Rehabilitation Journal, 31 (1), 70–75. Schwartz, L., Wright, D. & Lavoie-Tremblay, M. (2011). New nurses’ experience of their role within interprofessional health care teams in mental health. Archives of Psychiatric Nursing, 25 (3), 153–163. Siemsen, I. M. D., Madsen, M. D., Pedersen, L. F. et al. (2012). Factors that impact on the safety of patient handovers: An interview study. Scandinavian Journal of Public Health, 40 (5), 439–448.
202 Singh, B., Meadows, G. & Grigg, M. (2012). Mental Health Services in the Australian states and territories. In: G. Meadows, J. Farhall, E. Fossey, M. Grigg, F. McDermott & B. Singh (Eds). Mental Health in Australia, 3rd edn (pp. 118–154). Oxford: Oxford University Press. Tanenbaum, S. J. (2008). Consumer perspectives on information and other inputs to decision-making: Implications for evidence-based practice. Community Mental Health Journal, 44 (5), 331–335. Trenoweth, S. (2003). Perceiving risk in dangerous situations: Risks of violence among mental health inpatients. Journal of Advanced Nursing, 42 (3), 278–287. Victorian Government (1986). Mental Health Act 1986. [Cited 20 May 2014.] Available from URL: http://www.legislation .vic.gov.au/Domino/Web_Notes/LDMS/LTObject_Store/ LTObjSt5.nsf/DDE300B846EED9C7CA257616000A3571/ A7D40FD608D61455CA2577890007FEB8/$FILE/86 -59a098.pdf Victorian Government (2007). A review of Crisis Assessment and Treatment (CAT) services and functions. [Cited 20
A. WATERS ET AL. August 2013.] Availa ble from URL: http://health.vic.gov.au/ mentalhealth/publications/cat-review07.pdf Victorian Government (2014). The Mental Health Bill 2014- An explanatory guide. [Cited 20 May 2014.] Available from URL: http://docs.health.vic.gov.au/ docs/doc/The-Mental-Health-Bill-2014–An-explanatory -guide Walsh, J. & Boyle, J. (2009). Improving acute psychiatric hospital services according to inpatient experiences. A user-led piece of research as a means to empowerment. Issues in Mental Health Nursing, 30 (1), 31–38. World Health Organization Collaborating Centre for Patient Safety Solutions (WHOCCPSS) (2007). Communication during patient hand-overs. Patient Safety Solutions, 1 (3), 1–4. Yee, K. C., Wong, M. C. & Turner, P. (2009). ‘HAND ME AN ISOBAR’: A pilot study of an evidence-based approach to improving shift-to-shift clinical handover. Medical Journal of Australia, 190 (11), 121–124.
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International Journal of Mental Health Nursing (2015) 24, 193–202
doi: 10.1111/inm.12102
Feature Article
Handover of patient information from the crisis assessment and treatment team to the inpatient psychiatric unit Amanda Waters,1 Natisha Sands,2 Sandra Keppich-Arnold3 and Kathryn Henderson3 1
School of Nursing and Midwifery, Deakin University, Melbourne, 2School of Nursing and Midwifery, Deakin University, Geelong, and 3Alfred Psychiatry, Alfred Health, Melbourne, Victoria, Australia
ABSTRACT: Handover, or the communication of patient information between clinicians, is a fundamental component of health care. Psychiatric settings are dynamic environments relying on timely and accurate communication to plan care and manage risk. Crisis assessment and treatment teams are the primary interface between community and mental health services in many Australian and international health services, facilitating access to assessment, treatment, and admission to hospital. No previous research has investigated the handover between crisis assessment and treatment teams and inpatient psychiatric units, despite the importance of handover to care planning. The aim of the present study was to identify the nature and types of information transferred during these handovers, and to explore how these guides initial care planning. An observational, exploratory study design was used. A 20-item handover observation tool was used to observe 19 occasions of handover. A prospective audit was undertaken on clinical documentation arising from the admission. Clinical information, including psychiatric history and mental state, were handed over consistently; however, information about consumer preferences was reported less consistently. The present study identified a lack of attention to consumer preferences at handover, despite the current focus on recovery-oriented models for mental health care, and the centrality of respecting consumer preferences within the recovery paradigm. KEY WORDS: crisis assessment treatment team, handover, inpatient psychiatric unit, mental health, nursing.
INTRODUCTION Handover is the transfer of verbal and written communication of patient information between members of the health-care team. It is integral to the practice of all healthcare clinicians (Millar & Sands 2012). The Australian Commission for Safety and Quality in Health Care
Correspondence: Amanda Waters, School of Nursing and Midwifery, Deakin University, 48 Harrison Avenue, Burwood, VIC 3125, Australia. Email: [email protected] Amanda Waters, RN, BN (Hons). Natisha Sands, RN, BN (Hons), PhD. Sandra Keppich-Arnold, RN, GDHE&P. Kathryn Henderson, RN, GDACN. Accepted August 2014.
© 2014 Australian College of Mental Health Nurses Inc.
(ACSQHC 2011) recognizes the importance of handover in the continuum of health care, and acknowledges that information transferred between clinicians during the handover can directly affect the quality of care delivered to patients. Poor-quality handover practice has been linked to a number of unfavourable patient outcomes, including increased hospital stays, consumer dissatisfaction, delays in treatment, and other adverse clinical outcomes (Hill & Nyce 2010; Manser & Foster 2011; Siemsen et al. 2012; World Health Organization Collaborating Centre for Patient Safety Solutions (WHOCCPSS) 2007). In the present study, we report on the findings of a study that investigated handover between the crisis assessment and treatment team (CATT) and the inpatient psychiatric unit (IPU).
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There is little in the published literature that reports on handover practices in acute psychiatric settings, and no previous research that has specifically investigated handover between the CATT and the IPU. The lack of studies in this area is concerning, given that in Australia and internationally, CATT service models are in wide use to facilitate community access to psychiatric assessment and care for people who are experiencing acute mental health crises and associated risks of harm (Cotton et al. 2007; Hasselberg et al. 2011a,b; Johnson 2013). The initial assessment information attained by CATT is critical to guiding safe, high-quality consumer care (Singh et al. 2012), yet little is known about what types of information are communicated by CATT to the IPU, the way in which this information is transferred, or how this is used to guide care planning and interventions in the IPU. The CATT provides services for people with mental illness who are in psychiatric crisis in the community (Carroll et al. 2001; Hasselberg et al. 2011a; Johnson 2013, 2004; Singh et al. 2012; Victorian Government 2007). Psychiatric crises are characterized by acute disturbances of mental state and behaviour, and are associated with significant risks (Oliva & Compton 2008). Consumers experiencing acute psychiatric crises in the community are a vulnerable group, requiring timely intervention to ensure appropriate management of risks and assertive treatment for their condition (Carroll et al. 2001; Singh et al. 2012; Victorian Government 2007). Safe, effective management of consumers transferred from the community to an IPU requires a specialized team of multidisciplinary mental health clinicians working collaboratively to ensure the consumer receives quality care in a safe environment (Cotton et al. 2007; Deacon et al. 2006; Jones 2006; Singh et al. 2012). New South Wales Health (NSW Health 2012) recognizes the transfer of consumers from the community to the IPU as a highrisk process, and developed a policy to inform this procedure. One of the major principles stipulated throughout this policy is the importance of accurate and timely handover communication, particularly the accurate transfer of risk information. Communication failures are one of the main reasons for the occurrence of sentinel events in health care (WHOCCPSS 2007). The current emphasis on holistic patient care has resulted in health-care settings evolving into dynamic, multifaceted environments, where entire teams of multidisciplinary clinicians are directly or indirectly involved with a patient’s care (Bowers et al. 2009; Deacon & Cleary 2012). The importance of effective communication in acute psychiatric settings cannot be understated; communication failures can lead to inad-
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equate treatment outcomes, but can also place clinicians at significant risk of assault and injury (Kuehn 2010). Consumers presenting in psychiatric crisis require care that is cognizant of their risks as a means of promoting consumer and clinician safety (Sands et al. 2012). In an observational study examining risk communication at handover on an IPU, Millar and Sands (2012) found that risk information was often inconsistently communicated. They emphasized the need for consistency and accuracy in the transfer of information during handover, noting the strong link to consumer and clinician safety, as well as more favourable care outcomes (Millar & Sands 2012). In a study examining care transfers from the emergency department to medical wards, Horwitz et al. (2009, p. 701) used the phrase ‘dropping the baton’ to describe breakdowns in communication between multiple stakeholders, adding that communication breakdowns can lead to significant treatment errors and care disruptions. Studies examining emergency patient transfers identify different communication styles between clinicians, poor retention of information, and multiple interruptions as contributing to poor-quality handover (Bost et al. 2012; Evans et al. 2010; Owen et al. 2009). A number of recent studies examining handover practices in a variety of generalist clinical settings have recommended the use of structured handover tools, such as ‘ISBAR’ (Identify, Situation, Background, Assessment and Recommendation) or ISOBAR (Identify, Situation, Observation, Background, Action, Response), in order to improve the quality and consistency of handover practice (Bost et al. 2012; Millar & Sands 2012; Owen et al. 2009; Quin et al. 2009; Yee et al. 2009). Very few studies have examined the use of structured handover tools in psychiatric settings (Hunt et al. 2012; Poh et al. 2013), or handover practices in specialized mental health settings, such as CATT. The primary aim and focus of the present study was to identify and articulate the types of information communicated in the CATT to IPU handover, and the practices and processes used in information transfer. A secondary aim of the study was to explore care planning and interventions arising directly from information transferred in the handover.
MATERIALS AND METHODS This study employed an exploratory, descriptive design using an observational method. Nineteen structured observations of CATT to IPU handover were undertaken. All clinical documentation related to the handover completed within 24 hours of the consumer’s admission was © 2014 Australian College of Mental Health Nurses Inc.
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audited prospectively for information relevant to the handover, and evidence of care planning and interventions arising directly from handover information.
Setting The study was conducted at a major tertiary referral hospital in metropolitan Melbourne, Australia. The observations of handover were undertaken on one IPU, which comprised of 22 low-dependency beds and six highdependency beds.
Participants The study involved observations of CATT and IPU staff undertaking handover. The CATT is comprised of nursing, medical, and allied health staff who provide community-based psychiatric assessment and early treatment. A multidisciplinary team of medical, nursing and allied health clinicians staffs the IPU. Information sessions were held for CATT and IPU staff to explain the purpose of the research project. An information flyer explaining the project was left onsite in the staff offices, along with packages containing the participant information and consent form, and instructions for returning signed consent forms.
Ethical considerations The hospital and university Human Research and Ethics Committee granted ethical approval to conduct the research. A waiver of consent was sought for the use of patient information for the purposes of the documentation audit, as per the National Statement on Ethical Conduct in Human Research (NHMRC 2007).
Instrumentation A handover observation tool (Millar & Sands 2012), developed in a previous study examining IPU handover, was adapted for use in this study. The tool includes sections to record handover information communicated verbally and in writing, and whether this information was transferred into the consumer’s medical records. Consistent with the original tool, items such as the consumer’s age, diagnosis, sex, risk history, risk management plan, and mental state, were included, and three additional items were added to record psychiatric history, social status, and care planning outcomes arising from the handover. A separate section was added to the handover observation tool to record qualitative field notes taken at the time of handover. The original tool was pilot tested by Millar and Sands (2012), and the modified version of the tool was tested again in this study on the first three handovers observed. The tool was determined to be appropriate for collecting the data for this project. © 2014 Australian College of Mental Health Nurses Inc.
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Data collection Data were collected between April 2013 and August 2013. At the commencement of each handover, the researcher first confirmed that clinicians involved in the handover had provided written consent to participate in the study. The researcher then observed the handover and recorded the observations into the data-collection tool. Following the observation of the handover, all related clinical documentation for the following 24 hours was reviewed to verify which information communicated at the handover had been documented in the patient records, and to identify any care planning or interventions arising from the handover. Qualitative field notes were also taken at the time of handover to document any information pertinent to the handover not captured by the handover observation tool; for example, interruptions and their impact on handover, the handover environment, and descriptions of the handover process.
Data analysis Standard descriptive statistical analysis was performed on the quantitative data to calculate frequencies and percentages. All qualitative field note data collected during the structured observations were analysed using content analysis method (Krippendorf 2004). Content analysis provides a structured framework for analysing qualitative data. Using this method, key words and phrases are systematically analysed (frequency, repetition) to identify patterns and reoccurring themes in the data (Hsieh & Shannon 2005). A second researcher was then used to verify the themes generated from this iterative process.
RESULTS Nineteen observations of the CATT to IPU handover were undertaken during the data-collection period from April to August 2013. A total of six CATT clinicians and 14 IPU staff participated in the study. All participants were registered or enrolled nurses with 3 months–30 years of clinical experience in psychiatry. Admissions were categorized according to which CATT service had initially assessed and admitted the consumer. The majority (63%, n = 12) of consumers were admitted via emergency department CATT (ECATT). The admissions were then further categorized into Section 9 involuntary admissions (recommended under the Victorian Mental Health Act 1986; Victorian Government 1986) and voluntary admissions. The
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A. WATERS ET AL. TABLE 1:
Summary of findings of the CATT–IPU handover and documentation file audit
Information type Admission type
Section 9 admissions Patient diagnosis
Patient sex Verbal handover
Clinical file audit
Care outcomes
Variable
n
Frequency (%)
ECATT CATT Section 9 admission Voluntary admission ECATT admission CATT admission Schizophrenia Bipolar affective disorder First-episode psychosis Depression Generalized anxiety disorder Borderline personality disorder Other (unclear diagnosis) Male Female Psychiatric history Risk history Mental state Social status Care instructions Patient preferences Risk assessment Admission entry INAT Power chart CATT paperwork Seclusion/restraints PRN medications LDU/HDU Patient preferences
12 7 13 6 10 3 6 1 5 2 1 3 1 10 9 19 16 19 16 19 10 18 18 18 19 18 2 15 16 10
63 37 68 32 77 23 32 5 26 11 5 16 5 53 47 100 84 100 84 100 53 95 95 95 100 95 11 79 84 53
CATT, crisis assessment and treatment teams; ECATT, emergency crisis assessment and treatment teams; HDU, high-dependency unit; INAT, initial nursing assessment tool; IPU, inpatient psychiatric unit; LDU, low-dependency unit; PRN, pro re nata.
majority of consumers were admitted as involuntary patients under Section 9. ECATT admitted 77% (n = 10) of involuntary patients, as compared to CATT who admitted 23% (n = 3) of involuntary patients. Basic demographic data were collected on the consumer population. A summary of findings of the CATT to IPU handover is reported in Table 1. There were close to equal numbers of males 53% (n = 10) and females 47% (n = 9) admitted during the data-collection period. The consumers’ ages ranged from 18 years to 46 years, with the majority of consumers in the 35–44-year age range. While a variety of different psychiatric diagnoses were identified within the consumer population, the most common diagnosis was schizophrenia (32%, n = 6), followed by first-episode psychosis (26%, n = 5) and borderline personality disorder (16%, n = 3).
Content of verbal handover The results showed that the consumers’ psychiatric history (100%, n = 19), mental state (100%, n = 19), and care instructions (100%, n = 19) were consistently communicated during each occasion of handover. The consumers’ risk history and social status were mostly communicated during handovers (84%, n = 16). Consumer preferences were less frequently communicated in 53% (n = 10) of handovers.
Handover documentation audit Following the observation of handover, all clinical documentation produced within 24 hours of admission was reviewed to verify the types of information transferred from handover to patient medical records. Five types of documentation suites were identified as containing © 2014 Australian College of Mental Health Nurses Inc.
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information reported at handover; the risk-assessment document; the Initial Nursing Assessment Tool (INAT), which is the main tool used for formulating an initial nursing care plan and includes the consumer’s contacts details, community supports, and care preferences; the nursing admission notes; the CATT documentation and ‘power chart’; the electronic health record; and the database for clinical documentation accessible to all staff within the health service. The results of the documentation audit indicated consistent transferal of verbal handover information to the clinical documentation, and high levels of adherence with documentation. Consumer preferences are entered in the nursing admission file entry, as well as in the INAT. The INAT was considered complete if all documentation had been completed and an initial nursing care plan had been formulated within 24 hours of admission. The audit indicated that in almost half of the admissions (42%, n = 8), the section specifying the consumers’ preferences for care was left blank or incomplete.
Care-planning outcomes The most common care outcomes arising directly from the handover were the designation of low-dependency units (LDU)/high-dependency units (HDU) (84%, n = 16) and the administration of pro re nata (PRN) medications (79%, n = 15). Consumer preferences were facilitated in 53% (n = 10) of cases, and the use of seclusion or restraints arising from handover information was minimal (11%, n = 2).
Observations derived from qualitative field notes Field notes were taken at that time of the handover observation to describe events or issues that might have impacted on the conduct of the handover. Three important themes emerged from the content analysis of the field notes data: the handover environment, staffing profile, and the consideration of consumer preferences. The setting for handover was a medium-sized communal staff area with multiple access points. The handover room is enclosed on all sides by windows, giving a fish bowl-type effect. At any given time, the handover area could contain up to 20 nurses, doctors, allied health staff, and administration personnel in this confined space, with multiple conversations occurring simultaneously. The researcher observed that the room was extremely busy and crowded during nursing shift change (from the morning to the afternoon), where for approximately 2 hours, nursing staff numbers doubled. The following excerpt from the field notes reflects the challenges of © 2014 Australian College of Mental Health Nurses Inc.
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receiving handover within this setting during nursing shift changeover. Nursing shift change, many people in the room. AM staff is giving individual handovers to PM staff. There is nowhere for CATT to sit to give handover. Many conversations are taking place right now, very difficult to hear what is being said. The CATT clinician is speaking very quickly, the nurse is writing information down, but how much of it can they hear?
The most commonly-observed handover practice was for the CATT clinician to deliver handover to the IPU nurse in a continuous stream, without the use of a structured handover tool, such as the ISOBAR, to guide the conduct of the handover (Yee et al. 2009). The handover from CATT to the IPU nurse accepting the transfer of care was generally no more than 5 minutes from start to finish. However, prior to the CATT clinician’s arrival, the CATT had already provided a brief telephone handover to the nursing shift leader who would transcribe the information being transferred onto loose-leaf paper. The nursing shift leader would then provide a brief verbal handover and give the loose-leaf sheet to the nurse accepting the admission. These multiple points of communication meant that by the time the CATT clinician arrived with the incoming consumer, the nurse accepting the transfer of care usually had a reasonable second-hand account of what was to be expected during the handover. On several occasions, the consumers being admitted to the unit were well-known to staff. Handover for ‘wellknown’ patients was typically brief, and usually incorporated a reference to the clinicians’ familiarity with the consumer. There was an expectation from the clinician handing over that the consumer should be well-known, and therefore, little historical information was provided, as the following extract from the field notes illustrates: CATT clinician began handover by saying, ‘OK, introducing our good friend, Mr. X, very well-known to XXX Psych, we all know this young man. He left us 2 weeks ago, didn’t show up for his depot, and here we are!’.
The skill mix of clinicians working on the IPU was observed to be diverse; however, a significant proportion of the IPU nurses were observed to be junior staff working under the guidance and mentorship of senior staff. An important observation to arise from the study was that junior staff members were less likely to comment and ask CATT clinicians questions about the consumer during the handover than experienced staff. This was highlighted during one of the observations where the receiving nurse was very experienced and requested
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detailed consumer information in order to formulate a plan of care, as the following field note excerpt illustrates: The consumer is a high-aggression risk with a history of assault, and has been recommended for HDU. The nurse receiving handover is very experienced and asked many questions, such as ‘Does the consumer have a drug and alcohol history?’, ‘What sets this guy off?’, ‘Is there a history of mental illness in the family?’ The CATT clinician had to check the file several times to answer all his questions.
The participation of the nursing shift leader was also observed to be disruptive to the delivery of the handover. The nursing shift leader was subject to continuous interruptions, which resulted in a fragmented handover: The handover has been interrupted twice due to the shift leader being needed by ward staff and to speak to the bed manager on the phone. After the second interruption, the shift leader didn’t return, and the CATT clinician said they didn’t have time to wait around, plus the consumer was agitated and needed medication, so they just kept going.
Consumer preferences As previously noted, consumer preferences were communicated by the CATT to the IPU staff in approximately half of the handovers observed. The consumer preferences most frequently transferred at handover included requests for particular foods, telephone access to call family members, and requests for a single room versus a shared room. The following field note excerpt describes an occasion of handover where consumer preferences were transferred: Male consumer received under Section 9, no fixed address. He has no family or community supports, identifies a pigeon as being his only friend. He was happy to come into hospital until the CATT clinician opened up his suitcase and saw that he had packed a decomposing pigeon that had died earlier in the week. The CATT clinician told him that he would need to dispose of the pigeon, at which point the consumer became distressed and refused to be admitted. The CATT then agreed that the consumer could bring the pigeon to hospital and bury it in the ward’s courtyard, which the consumer agreed to.
The information about the pigeon was communicated verbally to IPU staff, recorded in the documentation, and this consumer preference was acted on according to the agreement made with the consumer.
DISCUSSION The present study found that neither CATT nor IPU staff utilized structured handover tools when delivering
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or receiving handover, despite the hospital guidelines for handover practice stipulating the use of ISBAR for handover. Although CATT and IPU clinicians were not observed to use handover tools, certain information types were consistently transferred across all of the handovers observed. Key clinical information, such as the consumer’s psychiatric history, mental state, risk history, social status, and care instructions, was consistently communicated at handover. Contrary to these findings, Millar and Sands’s (2012) study found that the risk information was communicated inconsistently, especially during the handover of consumers deemed to be ‘high-risk’ consumers. It is difficult to compare these findings in any meaningful way, due to the small sample size of the present study and the highly specific nature of the CATT to IPU handover, as compared to the routine shift-to-shift handover examined in Millar and Sands’s (2012) study. Consumer preferences were only reported in 53% of handovers in this study, despite clear expectations from the health organization for this to be completed in the INAT. Respecting consumer preferences and choices is a key theme of current Australian safety and quality literature (ACSQHC 2011), and this worldview is articulated in Standard 3 of the National Standards for Mental Health Services, Consumer and Carer Participation (Australian Government 2010). The notion of ‘consumer participation’ exemplifies person-centred care, where the needs, wishes, and goals of the person/consumer are used to tailor individualized care that addresses the holistic and unique needs of the consumer (Australian Government 2010; Fisher & Happell 2009; Frese III et al. 2001). Person-centred approaches to consumer care are also consistent with recovery-focused approaches to mental health care, which highlight the importance of being guided by consumer preferences, goals, and hopes in care planning (Fisher & Happell 2009). In the new paradigm of recovery-focused mental health care, a potential solution to the failure to adequately report consumer preferences at handover might be to actively involve consumers in the handover. This approach is also consistent with Standard 6 of the Handover Safety and Quality Improvement Guide, which states that the effectiveness of handover can be improved with active consumer participation (ACSQHC 2012). To date, no research has investigated the active participation of mental health consumers in handover. A factor that might have impacted on the consistency of reporting of consumer preferences was the acuity of consumers being handed over. It is possible that the consumers handed over in the present study were © 2014 Australian College of Mental Health Nurses Inc.
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unable to articulate their preferences for care as a result of being acutely unwell. In a study investigating serviceuser perceptions of telephone-based mental health triage, Elsom et al. (2013) found low levels of serviceusers’ involvement in decision-making, and that few service-users reported being asked about their preferences. Elsom et al. (2013) observed variations in the extent to which consumers in crisis want to, or feel able to, be involved in their care when experiencing psychiatric crisis. Scheyett et al. (2007) observed that during times of psychiatric crisis, consumers receiving treatment can experience a loss of autonomy and choices, resulting in potentially traumatic experiences and a reluctance to engage in future treatment. Tanenbaum (2008) found that consumers with mental illness value having a range of different treatment choices presented to them, and that the effectiveness of evidence-based interventions sometimes mattered less than being offered a choice. Fisher and Happell (2009, p. 182) echo this by stating: ‘If evidence-based practice does not take account of the human aspect of treatment, then it is not genuine recovery-oriented treatment’. Observations of handover in this study suggest that familiarity with the consumer might influence the duration and quality of the handover, a theme echoed in a study examining the practices of handover in a psychiatric rehabilitation setting (McCloughen et al. 2008). The handover of frequent service-users requires the same amount of attention to detail as the handover of new consumers; all consumer information should be updated regularly, and mental state and risk level should be reassessed on admission and thoroughly communicated at handover (McCloughen et al. 2008; Millar & Sands 2012). The most common care planning outcomes arising from handover identified in the present study were decisions to admit the consumer to LDU or HDU, and decisions to administer PRN medications. It was observed that immediate care decisions were frequently made during the initial telephone handover from CATT to the shift leader prior to the consumer’s arrival. These findings confirm that important care decisions typically arise from handover, and highlight the need for accuratelytransferred clinical information. The present study found that IPU clinicians are required to make rapid decisions about care based on the information provided to them in a brief CATT handover, and this reaffirms the need for effective and accurate communication at handover to facilitate safe, appropriate care (Fairbanks et al. 2007; Trenoweth 2003). © 2014 Australian College of Mental Health Nurses Inc.
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Transfer of care from community to inpatient settings Transfers of care from the community to the IPU were observed to involve several points of contact and types of communication to facilitate the process. Fairbanks et al.’s (2007) study revealed the complexity associated with multiple points of communication in emergency patient transfer, and identified care transfers as a patient safety issue. Mental health-care transfers are particularly complex (NSW Health 2012). A key recommendation of Millar and Sands’s (2012) study was the development of a structured handover tool that adequately captures specific risk information for use in acute psychiatric settings. Further research examining the CATT to IPU transfer and handover processes is required to determine the specific information requirements for the purpose of care transfers from the community to the IPU. The handover environment in this study was observed to be ‘busy’, and at times chaotic, with staff coming and going and multiple interruptions. Bost et al. (2012) reported similar findings in a study examining emergency department handover, where the chaotic and loud atmosphere presented several barriers to the paramedics delivering effective handover to emergency department staff. Participants were observed to have to repeat the content of handover several times to different clinicians, resulting in inconsistent information transferal (Bost et al. 2012). Interestingly, the present study found that in spite of the busy, noisy handover environment, there was a high level of consistency in the transfer of clinical information. An important insight gained from the present study was the potential impact of staff skill mix on the quality of handover, and the value of having experienced IPU staff present during the handover. Senior IPU staff participated actively in the handover and asked questions relating to the consumers’ care requirements, as compared to junior staff, who were passive recipients of the handover. Schwartz et al.’s (2011) study showed that junior nurses typically adopt a passive role to ‘fit in’. A more structured approach to handover that includes minimum standards for information exchange might facilitate more active participation in handover by staff at every skill level.
Implications for practice Acute inpatient settings have been criticized in recent literature for a perceived lack of consultation with consumers about their care (Fisher & Happell 2009; Frese III et al. 2001; Walsh & Boyle 2009) and lack of involvement in decision-making (Bowers et al. 2009). As mental health services move towards a more recovery-oriented approach (Australian Government 2009; Australian
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Government 2010), considering and communicating consumer preferences will become the expected standard in psychiatric settings (Australian Government 2009). The new Victorian Mental Health Act (2014) stipulates the importance of involving consumers in decisions about their care, and respecting consumer choices and preferences, as the following quote illustrates: ‘Persons receiving mental health services should be involved in all decisions about their assessment, treatment and recovery and should be supported to make, or participate in, those decisions and their views and preferences should be respected’ (Victorian Government 2014, p. 2). Consumer advocates also argue that greater emphasis should be given to ensuring that the consumer’s preferences are considered wherever possible to promote collaborative engagement (Fisher & Happell 2009). Within a largely-restrictive setting, such as an IPU, the consideration of care preferences via collaborative engagement with consumers can lead to improved service-user experience (Walsh & Boyle 2009). This study raises the question of how best to promote the inclusion of the consumer preferences in the delivery of handover in acute psychiatric settings. This study has a number of limitations. First, the generalizability of the study is limited due to the small sample size and the fact that it was a single-site study. A limited number of CATT clinicians participated in the handover, and therefore, it is difficult to determine with any accuracy how representative the practices observed in this study are of CATT handover practice. Second, a single researcher undertook the observations; the participation of other researchers in the data collection might have yielded different perspectives on handover. Nurses dominated the sample of clinicians in the study, even though CATT and IPU roles are multidisciplinary. Finally, it is possible that clinician practice was influenced by the presence of the researcher observing handover, and the impact this might have had on the study findings is unknown. The strengths of the study lie in its original contribution to the foundational body of knowledge on the CATT to IPU handover. Additionally, the use of a published handover observational tool for data collection and the prospective observational design were successful approaches that resulted in the study meeting its overall aims.
CONCLUSION Mental health-care transfers from the community to inpatient units are particularly complex and require consistent and accurate communication of information. Handover
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serves as the vital link in facilitating safe continuity of care, yet in spite of its importance to safety and continuity of care, little is known about the practice of CATT to IPU handover. Multisite research using large samples is now needed to extend on these findings and identify the minimum requirements for safe, accurate CATT to IPU handover that is inclusive of consumer choices and preferences.
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