What do you know about care homes? They so often seem to be those places on the edges of streets, estates, towns, even of society – right on the periphery of our vision and thinking, only becoming central and in focus at the time when us or a loved one needs to go in to one. But they are vital parts of our care systems and of our sense of being a civilised society. If you can’t have good places for people to live in and be cared for when they are at their most frail, what kind of society are we?
Care home is a generic term used to refer to care facilities which people live in that sometimes have nursing care (nursing homes) and some do not (residential care). The sector is very diverse. Most of it is now provided through the market by independent, for-profit organisations and by charities. Some are owned and run by those who manage them, others are parts of much larger organisations, and the numbers of residents varies considerably. It is estimated that around 400,000 people live in care homes, approximately three times more than the number of beds in the NHS. And these are people who generally have complex care needs.
There is much good practice in care homes, but there is also room for improvement in many. It is important that we understand what makes for good care in the homes, share it and help ensure it is enacted in all of them. I have previously blogged about some aspects of good practice in care homes and maintaining high quality in times of cuts in state funding.
In this blog I am going to look at a research report by Norrie and colleagues of a project looking at the handover process in care homes. This is the point where staff change over on duty. Those going off and coming on duty communicate with each other about what has happened in the home in the previous shift, how residents are doing, and what needs to be done in the next part of the day. This communication is likely to be a key aspect of making sure that staff know what is best for each resident.
In this study, Norrie et al. examined “the content, purpose and effectiveness of the handover of information about older residents between care home staff coming off duty and those coming on duty” (p.4).
They undertook a literature review of the current evidence on handover practice and collected data via observations of practice and interviews with a sample of staff in 5 care homes. The homes were chosen to reflect a range of characteristics of homes in the sector (e.g. ownership, size, with/out nursing). 27 staff were interviewed and 12 handovers were observed.
The interviews were recorded and transcribed. The transcripts and field observation notes made by the research team were analysed to examine for themes identified from the literature review and new ones emerging from the data.
In the literature review they found that handovers have been extensively researched in the NHS. They have been found to be well-established practice. Poor handover practice contributes to errors, accidents, delays and poor satisfaction amongst patients. The authors found that handovers in care homes had been much less researched, which seems out of balance with the importance of the sector as I outlined in the introduction above.
Handovers were seen as important by the staff interviewed. They were seen as fulfilling a range of purposes. In addition to basic communication about residents and care issues, some saw them as:
- matching skills to needs and allocating work,
- staff training,
- addressing some staff issues
- organising good person-centred care.
It is difficult to prescribe good practice in terms of timing and length of handovers and, as the interviewees found, both varied across the homes. Each home had specified times for handovers and these appeared to be adhered to.
There was variation in terms of who is involved in the handover and whether or not there was a discussion of each resident or only of exceptional circumstances. Some used a cascade system for handover, in which more senior colleagues undertook the formal handover and were then expected to cascade information down to colleagues in the homes. This variation in how information is shared and with whom may be related to the size of the homes (the smallest supported 22 residents whilst the largest had 150) and trying to find an approach that efficiently fitted local needs. However, the sense was more that it was down to local preferences about how to organise them.
Structure, tone and how information was recorded in handovers also varied across the homes. In part this arose from some having electronic care record systems whilst others had paper systems. Adaptations in practice to fit local circumstances is inevitable and sensible, but the authors commented that the variation they found even within this small sample of homes seemed “to depend on individual personalities and preferences” (p. 19).
There was also variation in the extent to which care assistants actively participated in the handovers. One interview said care assistants just listen rather than interrupt the nurses. Other interviewees reported feeling that it is important to actively include everyone involved in the handover.
One thing that was clear from the interview excerpts reported was the challenge of fitting efficient and effective handovers in to the busy schedules of the homes. Some staff were not paid for the handover time – for example, they came in early to do the handover process before their shifts formally began.
In the case study homes the handover seemed to be pretty regular and orderly events – but there were a few indications that this might not always be the case in all the homes, or indeed across the sector. One member of staff reported experience in other homes where handovers were not compulsory.
The authors discuss the limitations of the study. Five homes is not a large sample and it would be very difficult to claim that it is representative. The sample may well be biased towards homes that feel they have fairly good handover practice. But it would be difficult to gather a representative sample of homes across such a diverse sector. Furthermore, for the purposes of this exploratory study, aiming to learn about what is good practice rather than how extensively this is enacted, this is not a very significant limitation to the sampling.
The handover is but one relatively short part of a long shift for those working in care homes. But, as we know from research in health care, poor handovers contribute to poor care. Handover should to be seen as significant, and its value ought to be clear in each home. Surely one way to signal this would be to make sure that staff are paid for the time.
Another way to clearly indicate the importance of the handover would probably be to develop that more active engagement of all involved in the handover process. Given the possibilities for clearer communication, e.g. to correct errors and ensure an accurate, shared understanding, it would seem sensible to encourage staff to feel they can actively participate in the handover.
It is to be expected that handover practice will vary across homes, but there seemed to a worrying degree of variation in these case study homes. Further, if local practice depended too much on personalities, how can we be sure that any core of good practice in handovers is being consistently enacted across care homes? The study raises questions about our evidence base to support effective practice in handovers in care homes, and the extent to which current practice is consistently based on any sense of good practice versus local pragmatic and personal considerations.
As the authors note, the practice of handovers in care homes is undergoing some very interesting developments using technology. However, for even these to work we need a widely-shared understanding of the importance of handovers and the basic components of good practice in care homes. Norrie and colleagues have helped us to highlight this, and taken a useful step forward in helping us identify good practice and their report should be used across the sector to help reflect on local practice and how it might be improved. And, if you are choosing a home for yourself or someone else to live in, ask some specific information about their handover practice, including asking the care assistants whether or not they feel part of the process.
Caroline Norrie, Valerie Lipman, Jo Moriarty, Rekha Elaswarapu and Jill Manthorpe. How do handovers happen? A study of handover-at-shift changeovers in care homes for older people. Social Care Workforce Research Unit, February 2017.
David Oliver. Overcoming the challenges to improve health and wellbeing in care homes. The King’s Fund, 21 October 2016.
- Nicholas A. Tonelli CC BY 2.0