Evaluation of a clinical handover simulation training session for junior doctors in psychiatry

Abstract

Background

Clinical handover is an important aspect of patient care and medical education, as identified by trainee surveys. There is a need for robust, standardised handover systems. Situation, Background, Assessment and Recommendation (SBAR) is a communication and empowerment tool for standardised communication in healthcare. The purpose of this study was to evaluate the educational impact of a simulation-based educational session in clinical handover for trainees in psychiatry, using SBAR.

Method

A 3-hour session for trainees in psychiatry was designed with the North West Simulation Education Network and took place at the North Western Deanery School of Psychiatry. Presession and postsession questionnaires were completed, followed by a 6-week follow-up questionnaire.

Results

A significant improvement in participants' confidence and skills was demonstrated following the teaching session. Qualitative feedback also highlighted improved clinical application of the SBAR tool. Following the session, trainees reported an improvement in their appreciation of the role of other professionals in the handover process and a sense of empowerment when liaising with senior colleagues.

Conclusions

The training session potentially improved patient care by giving trainees structure, confidence and empowerment when talking to other colleagues while handing over. This may also help to meet the training requirements of the various Royal College curricula. This is the first study, to the best of our knowledge, which has evaluated a simulation session specifically designed to develop handover skills for trainees in psychiatry.

Introduction

Clinical handover is defined as ‘the transfer of professional responsibility and accountability for some or all aspects of patient care, on a temporary or permanent basis’.¹

The General Medical Council (GMC) requires doctors to ensure that suitable medical care arrangements, including effective handover procedures, are put in place when they are off duty.² In part, this is monitored through the GMC's annual trainee survey which has repeatedly highlighted handover as a major concern across a range of specialities, including psychiatry.³ The need for robust handover systems to ensure patient safety and trainee learning has also been documented in a number of reports in the UK, such as the Francis Report⁴ and by the British Medical Association (BMA).⁵ The latter recommends that protected time should be used for handover at a fixed time and length using a standardised system with ongoing professional development in the handover process.

Clinical handover in psychiatry is complex. Traditionally, this would take place face to face, within a hospital ward and would be unidisciplinary. Restructuring and development of mental health services has led to marked changes in delivery of care. Owing to the emphasis on delivering care in the community, inpatient overnight facilities have been reduced, resulting in a higher complexity of patients admitted to mental health hospitals. Additionally, there has been development of various teams with new multidisciplinary roles, taking on responsibilities that were previously held by a medic. Junior doctors are required to work across larger geographical areas, covering multiple sites and therefore, handovers are multifaceted.

A structured handover system was introduced into mental health acute units and community settings and this was found to be an effective way to escalate deteriorating patients.⁶ However, in psychiatry, there is evidence that handover can be problematic, with failures in communication identified as a root cause. This has included omission of information about a patient's condition or about the care plan for an unwell patient, leading to uncertainty in clinical decision-making.^7–9

Various Royal Colleges have devised curricula with specific competencies, including clinical handover, which doctors in training must attain before progression to the next stage.¹⁰ Handover is a good learning opportunity for trainees to develop their training competencies in communication, clinical assessment and management, as well as leadership and prioritisation.^{5 11} Some studies suggest that educational and training opportunities are not always available during handover.¹² A study in the North Western Deanery in North West England highlighted trainees’ concerns regarding communication during handover, particularly of medical problems and handover from peripheral hospital sites.¹³ Trainees in this study felt that handover was an important skill to learn, but found opportunities limited in current psychiatry training schemes.

The Situation, Background, Assessment and Recommendation (SBAR) communication and empowerment tool is a recognised technique for standardised communication in healthcare. SBAR was developed for use in healthcare by Kaiser Permanete, a non-profit American healthcare system to improve the handover (handoff) process. SBAR is a situational briefing tool that uses appropriate assertion and critical language¹⁴ to develop a common mental model.¹⁵ SBAR is also an empowerment tool, authorising more junior staff to request a response from more senior staff and across professional boundaries.¹⁶ SBAR provides a focused way to communicate patients’ conditions between professionals and set out clear expectations to senior team members. SBAR has been used in a variety of handover activities, including between healthcare professionals in a paediatrics/perinatal department,¹⁷ between nurses at a community behavioural health centre¹⁸ and in emergency situations. We found no evidence about the use of SBAR for doctors in mental healthcare settings.

As a consequence of these findings, we developed a simulation-based education session in clinical handover, focused on the effective use of SBAR. There have been other studies supporting simulation training to educate junior doctors in psychiatry¹⁹ and it has been shown that using simulated patients in training improves patient consultation performance among psychiatry trainees.²⁰ Simulation and role-play are used in teaching, assessment and research at all levels of training in psychiatric education.²¹ As far as we are aware, this is the first study that has evaluated a simulation session specifically designed for handover for trainees in psychiatry.

The purpose of this study was to evaluate the use of a simulation-based training session using SBAR as a communication tool for trainees in psychiatry. We aimed to improve trainees’ skills in clinical handover, their educational experiences and determine whether they were able to apply the training to their clinical work. We anticipated that participants might benefit from the course, particularly to enhance performance, confidence, clinical reasoning and communication during handover.

Methodology

Design

A simulation-based education session in clinical handover, using SBAR, for junior doctors was piloted and evaluated. The authors designed the session with support from the North West Simulation Education Network. An action research approach was applied, using feedback and subsequent reflection of previous work. This described concerns which trainees had in connection with their communication skills during handover, the handover of acute medical problems and handover from peripheral hospital sites.¹³ The session paid particular attention to the experience of handing over information to nursing staff and medical staff from other specialities.

Facilitators who had previous training and experience in providing feedback, debriefing and facilitating group discussions led the session. Before the session, the facilitators met on several occasions to clarify the structure of the session and discuss queries.

The session began with a PowerPoint presentation about handover and SBAR. Within the presentation, there were video examples of handover of variable quality. This was followed by an open discussion and reflection with participants about the examples shown in the videos and their own experiences of handover.

Following this, the trainees took it in turns to participate in four simulated clinical handover scenarios (table 1).

Table 1.

Simulated clinical scenarios

Scenario	Activity
1. Patient in mental health admissions ward requesting to leave	First trainee: Obtain information from ward nurse (phone) and assess the patient, then handover (face to face) to second trainee Second trainee: Receive handover from first trainee (face to face) and discuss case with consultant psychiatrist (phone)
2. Acute physical deterioration of patient on older adult mental health ward	First trainee: Review clinical notes and obtain handover from ward nurse (face to face) to ascertain patient's condition, then handover (face to face) to second trainee Second trainee: Receive handover from first trainee (face to face) and discuss with medical registrar (phone)
3. Acute mental health presentation in accident and emergency department	First trainee: Receive handover from A&E clinician (phone) and assess the patient, then handover (face to face) to second trainee Second trainee: Receive handover from previous trainee (face to face) and discuss with A&E nurse in charge (phone)
4. Face-to-face shift handover of three patients	First trainee gives shift handover of all the three patients above to second trainee

These scenarios had been written and peer reviewed in advance of the training session. The scenario themes were developed based on the challenges that clinical handover presented to trainees in psychiatry in the North Western Deanery.¹³ Each scenario included two participants to ensure a peer-to-peer handover.

The scenarios were facilitated by the multiprofessional session leads who took on the roles of patients and other healthcare professionals. Each junior doctor took it in turns to individually participate in the simulations with two doctors participating, in their own role, in each scenario.

Following each scenario, a video-assisted debriefing was facilitated using reflection as part of a learning process. Here, positive elements and performance gaps were identified and future learning actions discussed. Facilitators encouraged a participant-led discussion that enabled trainees themselves to offer feedback, learning points and suggestions for development. These were highlighted using video examples. Following the session, further individual reflective practice using their training portfolio and discussion with their clinical and educational supervisor was encouraged.

Participant selection

The aim was to facilitate this session, as a pilot, for a relatively small number of trainees to evaluate its effectiveness and outcomes. Then, look at how this could be scaled up for trainee doctors in the region. There were 132 trainee doctors within the North Western Deanery in the UK in a psychiatry placement. This included Core Trainees, GP trainees and Foundation Year doctors. These doctors were in supervised training placements in mental health trusts across Greater Manchester, Cheshire, Lancashire and Cumbria in the North Western Deanery in England. Most of these trainees work in a shift pattern and participate in an emergency on-call rota, which covers psychiatric inpatient units, with some covering multiple hospital sites. Some also cover the local Accident and Emergency departments in the region.

The junior doctors were initially contacted by email via the North Western Deanery School of Psychiatry and asked to show an expression of interest to take part in the session. The information about the study was contained within a detailed participation information sheet. For trainees who agreed to participate, written consent was gained on the day of the training session.

Evaluation

A sequential mixed-methods evaluation was used. Presession and postsession questionnaires were used to gather data, which comprised a mixture of Likert scales and free-text boxes to allow quantitative and qualitative responses. The questionnaires asked about communication skills and confidence in clinical handover in addition to difficulties they have faced with handover. The session was focused on handover skills, and not clinical assessment or management skills.

Six weeks following the session, the participants were asked to complete a follow-up questionnaire. This was disseminated as an online survey due to logistical issues of the geographically disparate group and clinical time pressures, making a second face-to-face follow-up session difficult to arrange. The aim of the 6-week follow-up questionnaire was to explore the participants’ application of what they learnt in the workplace and potential barriers to performing a structured handover in practice.

The data were analysed descriptively, while free-text comments were collated into themes by the authors.

This study received ethical approval from the North Western Deanery.

Results

Thirteen trainees responded to the original advert, with 11 participating on the day. The 11 trainees comprised 10 Core Trainees in psychiatry and 1 Foundation Year doctor, no GP trainees responded to the invitation to take part.

Presession and postsession quantitative analysis

Descriptive statistics (table 2) demonstrate a significant improvement in participants’ confidence in giving and receiving information following the teaching session (p<0.05). There was also an increase in awareness of errors in communication affecting patient safety, but this improvement did not reach statistical significance.

Table 2.

Presession and postsession quantitative results

	N	Presession, mean (SD)	Postsession, mean (SD)	Effect size	Wilcoxon signed-rank z score	p Value
Confidence handing over all information (score 0−5; 0, very unconfident; 5, very confident)	11	3.5455 (0.52223)	4.6364 (0.50452)	2.14	−2.972	0.003*
Confidence handing over information to nurse (score 0−5; 0, very unconfident; 5, very confident)	11	3.9091 (0.30151)	4.6364 (0.50452)	1.77	−2.828	0.005*
Confidence in accuracy/completeness of information received (score 0−5; 0, very unconfident; 5, very confident)	11	3.0000 (0.63246)	4.2727 (0.90453)	1.63	−2.345	0.019*
Confidence in accuracy/completeness of information received from nurse (score 0−5; 0, very unconfident; 5, very confident)	11	3.1818 (0.98165)	4.2727 (0.78625)	1.22	−2.588	0.010*
Perceived frequency of errors (score 0–5; 0, very rare; 5, very common)	11	3.7273 (1.34840)	3.8182 (0.98165)	0.08	−0.378	0.705
Perceived errors in communication (score 0−5; 0, not associated; 5, lead cause)	11	3.9091 (0.94388)	4.2727 (0.78625)	0.41	−1.414	0.157

*Statistical significance, p<0.05.

Presession and postsession qualitative analysis

Presession free-text questions asked about the trainee's knowledge of strategies and approaches to improve communication in handover. These fitted into the following themes.

Understanding the use of a standardised method to perform handover.

writing things down, handover log, standard proforma

The importance of regular training in handover.

We need to have ongoing, more regular training in handover skills

Postsession, free-text questions asked about the trainee's knowledge of strategies and approaches to improve communication in handover. These fitted into the themes listed here.

The importance of a structured approach to handover.

The structured approach to handover helps boost confidence especially when you feel out of your depth.

An awareness of others who participate in the handover process.

Try to put yourself in colleagues’ shoes and think of what to expect.

Follow-up results at 6 weeks

The participants highlighted that on reflection, the session had met their clinical learning objectives for handover,

The session highlighted many important issues in regards to psychiatric handover.

Gave us quite a structured approach for handing over.

The participants fed back that the session had improved their skills and confidence in handover.

It has improved my skills in handover especially during on calls.

Most (91%) of the trainees stated that they had used the SBAR tool in their clinical practice. They reported that using the SBAR tool helped them to structure a clinical handover and gave them confidence and empowerment when discussing with senior colleagues.

Yes, I have been using this not only in handover, but also in daily communication with colleagues.

Trainees highlighted that they found it to be a useful tool to minimise errors, helped them to structure a clinical handover and also wider clinical conversations not in a handover setting.

Yes, it has been especially helpful when speaking to the on-call registrar or consultant.

The trainees felt that the session helped to improve patient care and safety,

Yes by effectively handing over all the required details and actions need to be taken.

Sixty-four per cent of the trainees highlighted that they have reflected on the session in their portfolio.

The trainees were asked about the barriers that they have faced with regard to using SBAR with medical colleagues and other professionals. These were arranged into the following themes.

Colleagues who were part of the handover were not familiar with the SBAR tool and therefore not recognising it or using it correctly,

The other person may not be aware of the SBAR approach.

The use of a telephone being a barrier, as it is not face to face,

Often handover over the phone, not face to face.

Overall, the main themes highlighted were the importance of structure in handover and communication, educational opportunities and increasing confidence when discussing with seniors and colleagues from other professions.

Discussion

The purpose of this study was to evaluate the use of a simulation-based education session for trainees in psychiatry. The aim was to improve their handover skills and experiences and determine whether they were able to apply the training to their clinical work.

The presession and postsession evaluations reveal an improvement in trainees’ understanding and confidence in clinical handover. Previous research has shown that an introduction of a handover communication tool increases confidence in handover among junior doctors.²² Additionally, this session contributed to trainees feeling empowered about speaking to senior colleagues. More trainees became aware of SBAR as a handover tool and the importance of a structured approach to handover as a result of the session. They felt that this had a positive impact on patient safety.

The trainees highlight how the sessions had met their training needs in handover according to their curriculum, which addresses some of the concerns raised by trainees in the North Western Deanery.¹³ A particularly interesting finding was that following the session, the trainees also demonstrated awareness of others’ perspectives. This suggests that this form of handover simulation teaching was able to highlight other clinicians’ viewpoint when communicating information. This is an important feature of collaborative working, particularly within a multidisciplinary team. This is especially relevant in psychiatry, given that consultants in the UK often work across more than one team, with various professionals in each team. The ability to appreciate other practitioners’ perspectives (and indeed patients' perspectives) is a theme throughout the Clinical Leadership Competency Framework (CLCF) in the UK. This emphasises one of the themes of effective clinical leadership, which is to recognise one's own views, values and principles and how these may differ from others in all clinical situations.²³ The results of our evaluation reaffirm previous findings highlighting the value of standardised training for handover and tailoring this for the setting and speciality.²⁴

This study has some limitations. While the analysis demonstrates improvement in participants’ confidence in giving and receiving information following the session, we are treating the statistical significance with caution as we recognise that the sample size is small. A larger cohort would allow for further refinement and evaluation of the session, for instance, analysing the educational impact of the video recordings used in the feedback. We recognise that some valuable learning may have come from these and a suggestion for development would be to incorporate these into future simulation sessions.

The trainees who attended the session participated on a voluntary basis, this may reflect that they are more motivated and training focused. It may also have been useful to have observers during the workshop that could give objective feedback about their impressions of the session. A suggestion for future evaluation would be to obtain face-to-face feedback, rather than an online follow-up questionnaire, for example, through focus groups. This may generate more discussion and therefore richer feedback. More specifically, we would have gained information on what the participants’ experience was of the teaching, the reasons why participants felt learning occurred and the impact of the course on actual practice.

There will be confounding factors in relation to the accuracy of follow-up data and how this is interpreted. Participants will have picked up other skills between the session and the 6-week follow-up. This would impact on the responses given. Additionally, the variable level of knowledge about the SBAR tool will have impacted on the data collected. This has drawn our attention to adapting our sessions in response to the participants’ existing knowledge and sending out the presession questionnaires at an earlier stage in order to establish this.

The majority of the trainees were at Core Trainee one level, which may limit the generalisability of the study to other grades and groups of trainees and professionals. Suggestions for clinical practice would be to ensure that a whole organisation supports and develops skills in the use of a standardised tool for handover such as SBAR. One of the themes at the 6-week stage was that colleagues were not familiar with the SBAR tool and therefore not recognising it or using it correctly. There should be training available for doctors (and wider professionals) to practice using SBAR as a handover tool. Delivering interprofessional training and sessions across specialities will also allow staff to overcome the barrier of judging what information is important and relevant to other professionals and specialities. This training need has been highlighted previously.²⁵ Interprofessional training should reduce barriers and increase confidence in communicating across professions. Clinicians may highlight the use of SBAR to trainees through demonstrating the use of it in their clinical work. We would recommend that trainees’ mandatory induction programme incorporate a session in clinical handover and using the SBAR tool, and this should be followed up in clinical and educational supervision.

The faculty took on the roles of the patient and other healthcare professionals; it was felt this was appropriate for this pilot but may have introduced some biases and risks supporting negative professional stereotyping. It is hoped that inclusion of other professional groups as participants would improve the quality and repeatability of the session. It is also thought that recruitment and training of volunteers as simulated patients would improve the quality and repeatability of the session. Additionally, simulated patients could provide the opportunity to get lay feedback on the clinical interactions. It is anticipated that these simulated patients and other blended learning and prelearning resources will be developed to support a number of simulated sessions.

Conclusion

The use of a simulation-based educational session for psychiatry trainees in order to improve their handover skills and experiences was a positive development. Trainees felt more confident in handover and empowered when talking to senior colleagues. They also became aware of strategies to improve communication across professional boundaries and to senior staff. Additionally, they began to consider what information is relevant depending on the situation and the impact that handover has on other people involved in the process. Such sessions using simulation may improve patient care and safety by allowing trainees to develop and practice their skills and meet the training requirements of the various curricula.