Finessing Clinical Handover
We all know the common steps of clinical handover with ISBAR, they are recapped below.
Identify / Introduction
Your name and role
Check who you are speaking with
Say who you are speaking about
Situation
What has happened?
Why you are calling?
What do you need help with
Background
Relevant health issues and relevant past medical history
Assessment
Your assessment, including observations, what is happening now?
Recommendation/Request
Next steps, or what help do you need?
Clinical handover, may be in-person, over the phone or written. In all cases its important we do this as effectively as possible.
We try to prepare and plan for everything, but sometimes our best laid plans can be thrown off course.
Here are some pitfalls to look out for, and some strategies to help.
Remembering the “I” in ISBAR
For different reasons this obvious step is sometimes missed and it can feel hard to go back to correct this. The risks of not confirming details include:- loss of details/continuity for future discussions, giving advice that the receiver can’t use or even giving advice on the wrong patient!
Unless it is the most acute emergency there is usually time to get a few identifying details.
Remember to get names, identifiers and roles as well as give your name and role.
Power imbalances
If someone is calling you for advice, a consult, or transfer of care, the chances are you have some experience that they do not and they need access to . Within the culture of medicine this is often associated with a power imbalance.
They could potentially feel nervous or worried about making the referral, especially fearing they are underprepared. They may also have limited options for help, this referral is probably very important to their next steps, which adds a weight of responsibility.
Here are some tips to address power imbalances, with communication micro-skills highlighted in bold.
For experienced clinicians
Awareness of where the power sits conscious steps to address this will go a long way. Aim to reassure, and also make it clear that you are listening to help achieve the best outcome for the patient.
Introduce yourself well and build rapport with empathy
“How is your day going?” “Sounds like a challenge…”
Pick up and respond to cues, particular if they suggest the person may be nervous (e.g. a rapid stream of speech). Take steps to reassure them.
“It can be hard making these calls when you’re in the middle of a stressful day, please tell me the story and I’ll see what I can do to help”
Add structure
“So I can help you best, please tell me the issues and background then I’ll ask you a few specific questions and we can come up with a plan”
If you’re interrupted or distracted let them know
“Sorry I was distracted by another call coming through, can you repeat the last bit”
Check for understanding
“To check we’re on the same page can you let me know what you understand about next steps?”
For doctors-in-training or other clinicians
You who may feel worried about speaking to the more experienced clinician. Know that the person you’re speaking with wants to help you get the best resultful your patient, they know this is in everyone’s best interests.
They may need a bit of time to orient themselves to your concern (particularly if they have been receiving multiple referrals, or for calls overnight).
Use pauses and pacing to ensure they have time to follow you
Use asking permission to signpost the goal of discussion
“Is it ok if I discuss this (patient/issue) with you?
“Are you/Have I got the right person to discuss … with?”
Headline what you’re worried about - share your thinking.
“I’m most worried that this is the patients 3rd MET call in 3 days over this long weekend”
“I’m most worried that this patient is developing sepsis but I am unsure of the source”
“I’m thinking that there could be…”
Use structure - ISBAR is excellent for this, add structure phrases such as
“I have some specific questions about this case if thats ok”
You can also check your understanding of the plan
“To check we’re on the same page can I let you know what I understand about the next steps?”
Or “So, this is the plan I will document, please let me know if I’ve missed anything”
For colleagues with similar experience/seniority
Clarity is key, it’s easy to assume you both know what you’re talking about and the plan, it might feel unnecessary or uncomfortable to check you agree, but don’t miss this step.
“So just to check we’re on the same page, I will do … and you’ll do …?”
Interruptions
It’s tempting to do this as early as possible. Those of us receiving the handover will likely have an idea of what we want to know, and have well worn checklists in our minds for important details.
Unfortunately, early interruptions and too many interruptions will throw our colleagues off balance, and may lead to them forgetting to share important details or concerns.
Aim listen to their handover of key details first, you’ll have time to question later.
If you do need to interrupt, try signposting your interruptions and the reason why
“Sorry I am just need to stop you there as you’ve mentioned a really important detail, can I check..?’
“Thanks, now please continue with…”
General tips
Especially for phone conversations signpost everything, make the conversation as obvious as possible to make up for the missing non-verbal cues. Ask for clarity if there is any uncertainty.
Remember your “Request” can also include saying your looking for advice as you are not sure about next steps. Its helpful to have this clear early on.
Update your patient and/or their family about any significant changes in plan or about any delays in decision-making.
Document the discussion succinctly, including who you spoke to, next steps, and the plan if the issue persists.
And finally, remember to thank each other for a job well done.
Next steps?
So we’ve recapped the ISBAR structure for clinical handover, and we’ve considered some specific communication strategies to make the most of our clinical handovers.
Take a look at the clinical handovers happening around your workplace, and consider where some of these tips would help.
For more on ISBAR for clinical handover
