Handover awareness and quality in maternity handover
Almost half (47%; n = 14) of the participants described having some awareness of a handover process prior to being invited to take part in the study, with 8 (27%) having experienced this through the shared care model of antenatal visits. Once the concept of handover was introduced to those who were previously unaware of handover, all reported instances of handover. The most frequently reported evidence that handover had occurred were: clinician's awareness of information about a patient which they had not previously discussed with that patient (57%; n = 17), patient being present during a verbal handover (50%; n = 15), the existence of documentation (e.g. a hand-held patient record) as an example of written handover (36%; n = 11), and patients' awareness of shift changes (23%; n = 7).
Clinicians' awareness of patient information was interpreted by some women as representing positive aspects of teamwork, care and communication (i.e. representing consistency of team care and communication, efficient flow of work and professional conduct), and was reported in this way by five (17%) women. One woman also reflected that the way a lactation consultant spoke to her represented an awareness of her case pre-dating their discussion review. She reported that this gave her the feeling that this clinician understood her current problems.
One-third of participants specially mentioned that handovers were done to their satisfaction or better. These women referred to the idea of a "good" handover as those that represented that clinicians were doing a good job (13%; n = 4), resulted in patients having a positive or pleasant experience (10%; n = 3) and made them feel confident/safe in the care provided (10%; n = 3).
Cross-checking and cognitive artefacts supporting maternity handover
The ability to cross-check information was mentioned by 16 participants (53%). There was reference to the patient being involved in the cross-checking (43%, n = 13) and of observed direct inter-professional cross-checking (10%, n = 3).
Participants described the use of articles to assist cognition and memory [
26] in maternity handover and clinical communication through their interviews. The most frequently mentioned cognitive artefact was patient authored birth plans (50%, n = 15), followed by medical records including patient charts (27%, n = 8).
The cross-checking of the cardiotocograph (CTG) was reported by two participants. Cross-checking of items (e.g. CTG interpretation) with another clinician was regarded by one participant to be good professional practice.
The medical record was used in a range of locations in pregnancy care (antenatal clinic, shared antenatal care with the community general practitioner, birth suite, transfers between departments and the ward) whereas the patient authored birth plan was exclusively referred to in the birth suite.
Cognitive artefacts were perceived to support handover by being an archival form of delayed handover, as prompting memory during handover, or as a means to facilitate the cross-checking of information for accuracy, detail or to fill in perceived gaps as required. Although all participants were English-speaking, one believed that officially documenting clinical information to support handover may be particularly important for non-English speaking patients (who were excluded from the current study).
Some participants felt that certain pieces of information were important to both officially document in their medical record and verbally handover (20%; n = 6), such as relevant medical history (e.g. substance dependence), preferences about Konakion (Vitamin K) for the newborn, preferences regarding episiotomy, or requirement for an interpreter.
Participants also observed clinicians making distinctions about information that should be documented as well as verbally handed over. One woman described how a plan for her management was documented, shown and discussed with her by a clinician, in addition to being verbally handed over which she considered good practice. Consistency in management was important to her.
The most frequently reported cognitive artefact was the patient-authored Birth Plan (50%; n = 15). As one participant said, "I orchestrated my own handover." When a Birth Plan existed, some patients were happy for just an awareness of its existence (30%; n = 9) or just the relevant parts (10%; n = 3) to be verbally handed over as it could be checked for detail later (17%; n = 5). One participant did not have a written Birth Plan, but had developed a verbal Birth Plan with her husband and felt it was his duty to make her wishes known in labour.
Although cognitive artefacts by design may be used to enhance the quality and safety of maternity handover through assisting memory and cognition, participants described incidents in their care where there were problems. For two patients where documented patient-authored Birth Plans were present, points that the patient believed were important were perceived to be not recognised or handed over by clinicians. These women described instances: 1) where there was a failure to provide analgesia (nitrous gas or pethidine) in a timely manner when requested by the patient, and 2) when a patient's partner was not offered the opportunity to cut the umbilical cord at birth without an explanation given as to why this was not possible. One of these patients however offered suggestions to avoid similar incidents in the future. Her suggestions were twofold: placing the patient-authored Birth Plan in a visible place, such as being stuck to the door, and dedicating a session during Childbirth Education to Birth Plans. She also suggested that the hospital offer interested patients standardised templates for patient-authored Birth Plans. The other affected patient wondered whether the lack of consideration of her Birth Plan might reflect how different Birth Suites (with different models of care) attributed different levels of importance to patient-authored Birth Plans. This patient had been transferred from a lower-risk, midwifery-care Birth Suite to a higher-risk Birth Suite intra-partum when this event occurred.
Formal antenatal hand-held records were perceived to be ineffective in supporting handover and clinical communication by one patient who had received shared antenatal care. Her observation was that the hospital clinicians and the general practitioner did not read notes from previous visits with the other service at each of her visits. In particular, she felt rushed in the hospital clinic which she perceived may have contributed to clinicians not reading previous notes in her handheld record. This experience made her consider having all her care within the hospital for her next pregnancy, as she had observed good team work and shared awareness of clinical information between hospital clinicians.
Participation of patients and support people influencing the quality and safety maternity care
Within the interviews, a common theme referred to patients and their support people's involvement in maternity handover and care, and how that impacted on quality and safety. In the Birth Suite setting in particular, over half of the participants preferred handover to occur in their presence inside the Birth Suite room. For a few, this was influenced by the stage of labour. In particular, five women did not wish to be present at handover in second stage (17%; n = 5) so not to distract or distress them at that time (13%; n = 4).
The ability of the patient to clarify, add, validate and update information at the time of handover was described (37%; n = 11), with one patient commenting that "patients often have more information than you [clinicians] anticipate." If the patient was not present during handover, the ability to supplement, clarify and update information later in the shift was also felt to be important (23%; n = 7). Particular information that women believed should be cross-checked was their preference for episiotomy, syntocinon for third stage management, Hepatitis B vaccination and/or vitamin K injection for the newborn, as well as whether clinical issues that were handed over between clinicians were still a problem. Two patients also commented that it was the support person's role to make patient wishes known and be involved in the cross-checking of the patient-authored Birth Plan with clinicians during labour; one observed their support person (husband) in the Birth Suite being involved in handover and believed it was the clinicians' duty to facilitate this involvement.
Some participants reported they had the right to know information that was handed over and discussed (13%; n = 4). A couple specifically described the importance of being involved in discussions that took place in their presence (7%; n = 2). Two women commented that staff had included them in their pregnancy care and cited that patient involvement was encouraged by the avoidance of technical jargon/acronyms (7%; n = 2) or being patronising in their discussion (3%; n = 1).
Understanding of current management decisions (10%; n = 3) was an important factor for some when the management plan was constantly changing (7%; n = 2). This regularly happens during labour, impacting on patient-authored Birth Plans, as one woman had mentioned. Similarly, to participate in shared decision making was considered reassuring or useful by the patient (10%; n = 3). Some participants felt that they did not always need to be present during handover in order to have input; they specifically identified ways in which this input could occur: including information from prior patient-clinician discussions (13%; n = 4), referring to patient-authored Birth Plans (50%; n = 15); and consideration of patient's emotional state in labour, such as coping and distress (23%; n = 7). In this way, participants felt that they continued to have an impact on decision-making, despite their physical absence.
However, not all women were consistently happy to take a role in enhancing the safety and quality of handover. Eight women (27%) specifically did not wish to be present in handover during labour. Six women (20%) expressed feelings of vulnerability when asked about the concept of being present and/or involved with handover in the labour setting. One woman when asked by a clinician why a particular investigation was being done, wondered why this information was not handed over, either verbally or through documentation, and therefore questioned whether she needed to have it done at all. Similarly, another woman felt that clinicians' expertise and authority were undermined if they asked their patients about information or decisions which had been previously discussed with another clinician. In addition, four women (13%) felt that their presence at handovers during labour may negatively impact on the discussion taking place. Other negative effects mentioned were: increased handover time, hampered professional discussion, patient interruptions, or increased risk of panic though misunderstanding the information discussed; in particular, the latter point was perceived by some of our English speaking participants to be a problem for women with little or no English.