Participation and experience of third-year medical students in handoffs: time to sign out?

Evaluating the Implementation of a Medical Student's Handoff Curriculum During the Surgery Clerkship

INTRODUCTION

Early introduction to essential communication skills is important. We sought to determine if a handoff curriculum (HC) would improve confidence, decrease anxiety, and increase participation in clinical handoffs during the surgical clerkship.

METHODS

A multi-center prospective cohort study was performed at two medical schools. Training in the intervention group (HC) consisted of a didactic lecture, video review, and practice session. Students completed a pre-clerkship knowledge test and confidence/anxiety/handoff experience questionnaire pre- and post-clerkship.

RESULTS

There were no significant differences in pre-clerkship handoff experiences between institutions except having previously witnessed a verbal handoff (School A 96.4% versus School B 76.2%, P = 0.01). While there were no significant differences in post-clerkship confidence or anxiety, HC students were significantly more involved with written sign-outs (52.9% versus 18.2%, P = 0.02) and verbal handoffs (29.4% versus 4.6%, P = 0.03).

CONCLUSIONS

Medical students exposed to handoff training shared similar confidence and anxiety scores compared to those that were not, however, they were more involved in handoff experiences during their surgical clerkship. Early introduction to handoff skills may encourage greater participation during subsequent clinical experiences.

Evaluating the Association of a Core EPA-Oriented Patient Handover Curriculum on Medical Students' Self-reported Frequency of Observation and Skill Acquisition

INTRODUCTION

"Giving or receiving a patient handover to transition patient care responsibility" is one of the thirteen Core Entrustable Professional Activities (Core EPAs) for Entering Residency. However, implementing a patient handover curriculum in undergraduate medical education (UME) remains challenging. Educational leaders in the multi-institutional Core EPA8 pilot workgroup developed a longitudinal patient handover UME curriculum that was implemented at two pilot institutions.

MATERIALS AND METHODS

We utilized multi-school graduation questionnaire data to assess the association of our patient handover curriculum on self-reported frequency of observation/feedback and skill acquisition by comparing data from the shared curriculum schools to data from other Core EPA pilot schools (three schools with school-specific curriculum; five without a dedicated handover curriculum). Questionnaire data from 1,278 graduating medical students of the class of 2020 from all ten Core EPA pilot schools were analyzed.

RESULTS

Graduates from the two medical schools that implemented the shared patient handover curriculum reported significantly greater frequency of handover observation/feedback compared to graduates at the other schools (school-specific curriculum (p < .05) and those without a handover curriculum (p < .05)). Graduates from the two shared approach schools also more strongly agreed that they possessed the skill to perform handovers compared to graduates from the other eight pilot schools that did not implement this curriculum.

CONCLUSION

The findings of this study suggest that the implementation of a multi-institutional Core EPA-based curricular model for teaching and assessing patient handovers was successful and could be implemented at other UME institutions.

Efficacy of a blended learning programme in enhancing the communication skill competence and self-efficacy of nursing students in conducting clinical handovers: a randomised controlled trial

BACKGROUND

A clinical handover is an essential nursing practice that ensures patient safety. However, most newly graduated nurses struggle to conduct clinical handovers as they lack sufficient communication skill competence and self-efficacy in this practice. This study aimed to examine the efficacy of a blended learning programme on the communication skill competence and self-efficacy of final-year nursing students in conducting clinical handovers.

METHODS

A randomised controlled design was used. A convenience sample of 96 final-year baccalaureate nursing students at a local university. Data were collected in 2020. Participants were randomly assigned to either an experimental group (n = 50) that received a blended learning programme with face-to-face training and an online module on handover practice, or a waitlist control group (n = 46) that received only face-to-face handover training during the study period and an online module immediately after the completion of data collection. The primary outcome was the communication skill competence and the secondary outcome was the self-efficacy of the participants in conducting clinical handovers. An analysis of covariance was used to examine the between-subjects effects on self-efficacy and communication skill competence in conducting clinical handovers after controlling for the significantly correlated variables. A paired sample t-test was used to determine the within-subjects effects on self-efficacy.

RESULTS

The participants in the experimental group had significantly higher communication skill competence (p < 0.001) than those in the waitlist control group. Although both groups showed a significant improvement in self-efficacy, the mean scores of the experimental group were higher than those of the waitlist control group (p < 0.001).

CONCLUSIONS

This study demonstrated the efficacy of a blended learning approach in improving the communication skill competence and self-efficacy of final-year nursing students in conducting clinical handovers. Nurse educators should incorporate a blended learning approach into the nursing curriculum to optimise the content of training programmes for teaching nursing students in conducting clinical handovers.

TRIAL REGISTRATION

The study protocol was registered in the Registration ClinicalTrials.gov ( NCT05150067 ; retrospective registration; date of registration 08/12/2021).

Newly graduate nurse perception and experience of clinical handover

BACKGROUND

Clinical handover is challenging for newly graduated nurses. Previous studies have showed that many new graduates perform handover ineffectively and unsystematically; however, our knowledge of newly graduated nurse perceptions of handover, including barriers and challenges to handover, is incomplete.

OBJECTIVES

The study aimed to explore newly graduated nurse experience of clinical handover in Hong Kong public hospitals.

DESIGN

This was a descriptive phenomenological study.

SETTING

Participants were recruited from 11 public acute care hospitals in Hong Kong.

PARTICIPANTS

The participants were a convenience sample of 20 nurses who had graduated within the previous 12 months.

METHODS

Individual semi-structured interviews were conducted, and the data were analysed using content analysis.

RESULTS

Three themes emerged from the data: 'significance of clinical handovers,' 'feelings of frustration about clinical handover,' and 'perceived barriers to handover.' Participants perceived clinical handover as an essential nursing practice in the provision of continuous patient care. Further, some new graduates experienced stress and anxiety in clinical handover, which severely affected their quality of life. Perceived barriers to handover included inadequate professional judgement, poor ability to synthesize the important information, and unsystematic reporting.

CONCLUSIONS

Newly graduated nurses face challenges and encounter difficulties in performing clinical handover. Handover theory and, in particular, skills training should be introduced into the undergraduate nursing curriculum, to arm students with the confidence and competence to perform appropriate clinical handover.

Nursing students' involvement in shift-to-shift handovers: Findings from a national study

BACKGROUND

Effective performance of clinical handovers should be one of the priorities of nursing education to promote efficient communication skills and ensure patient safety. However, to date, no studies have explored to what extent nursing students are involved in handovers.

OBJECTIVE

To explore nursing students' handover involvement during their clinical rotations and associated factors.

METHOD

This was a secondary analysis of a large national cross-sectional study that involved 9607 undergraduate nursing students in 27 universities across 95 three-year Italian baccalaureate nursing programs. The involvement in the clinical handovers was the end point (from 0, never, to 3, always). A path analysis was performed to identify variables directly and indirectly affecting students' handover involvement.

RESULTS

Handover involvement was reported as 'only a little', 'to some extent', and 'always' by 1739 (18.1%), 2939 (30.6%), and 4180 (43.5%) students, respectively; only 749 (7.8%) of students reported never being involved. At the path analysis explaining the 19.1% of variance of nursing students' involvement, some variables emerged that directly increased the likelihood of being involved in handovers. These were being female (β = 0.115, p < 0.001); having children (β = 0.107, p = 0.011); being a 3rd-year student (β = 0.142, p < 0.001) and being a 2nd-year student as compared to a 1st-year student (β = 0.050, p = 0.036); and having a longer clinical rotation (β = 0.015, p < 0.001) in units with high 'quality of the learning environment' (β = 0.279, p < 0.001). Moreover, students who were supervised by the nurse teacher (β = -0.279, p < 0.001), or by a nurse on a daily basis (β = -0.253, p = 0.004), or by the staff (β = -0.190, p < 0.001) reported being less involved in handovers as compared to those students supervised by a clinical nurse. Variables with indirect effects also emerged (model of student's supervision adopted at the unit level, and number of previous clinical rotations attended by students). Moreover, handover involvement explained 11.5% of students self-reported degree of competences learned during the clinical experience.

CONCLUSIONS

Limiting students' opportunity to be involved in handover can prevent the development of communication skills and the professional socialization processes. Strategies at different levels are needed to promote handover among undergraduate nursing students.

Characterising ICU-ward handoffs at three academic medical centres: process and perceptions

BACKGROUND

There is limited literature about physician handoffs between the intensive care unit (ICU) and the ward, and best practices have not been described. These patients are uniquely vulnerable given their medical complexity, diagnostic uncertainty and reduced monitoring intensity. We aimed to characterise the structure, perceptions and processes of ICU-ward handoffs across three teaching hospitals using multimodal methods: by identifying the handoff components involved in communication failures and describing common processes of patient transfer.

METHODS

We conducted a study at three academic medical centres using two methods to characterise the structure, perceptions and processes of ICU-ward transfers: (1) an anonymous resident survey characterising handoff communication during ICU-ward transfer, and (2) comparison of process maps to identify similarities and differences between ICU-ward transfer processes across the three hospitals.

RESULTS

Of the 295 internal medicine residents approached, 175 (59%) completed the survey. 87% of the respondents recalled at least one adverse event related to communication failure during ICU-ward transfer. 95% agreed that a well-structured handoff template would improve ICU-ward transfer. Rehabilitation needs, intravenous access/hardware and risk assessments for readmission to the ICU were the most frequently omitted or incorrectly communicated components of handoff notes. More than 60% of the respondents reported that notes omitted or miscommunicated pending results, active subspecialty consultants, nutrition and intravenous fluids, antibiotics, and healthcare decision-maker information at least twice per month. Despite variable process across the three sites, all process maps demonstrated flaws and potential for harm in critical steps of the ICU-ward transition.

CONCLUSION

In this multisite study, despite significant process variation across sites, almost all resident physicians recalled an adverse event related to the ICU-ward handoff. Future work is needed to determine best practices for ICU-ward handoffs at academic medical centres.

Patient Handoff Education: Are Medical Schools Catching Up?

Communication errors during shift-to-shift handoffs are a leading cause of preventable adverse events. Nevertheless, handoff skills are variably taught at medical schools. The authors administered questionnaires on handoffs to interns during orientation. Questions focused on medical school handoff education, experiences, and perceptions. The majority (546/718) reported having some form of education on handoffs during medical school, with 48% indicating this was 1 hour or less. Most respondents (98%) reported that they believe patients experience adverse events because of inadequate handoffs, and more than one third had witnessed a patient safety issue. Results show that medical school graduates are not receiving adequate handoff training. Yet graduates are expected to conduct safe patient handoffs at the start of residency. Given that ineffective handoffs pose a significant patient safety risk, medical school graduates should have a baseline competency in handoff skills. This will require medical schools to develop, implement, and study handoff education.

Effect of handoff skills training for students during the medicine clerkship: a quasi-randomized study

Continuity is critical for safe patient care and its absence is associated with adverse outcomes. Continuity requires handoffs between physicians, but most published studies of educational interventions to improve handoffs have focused primarily on residents, despite interns expected to being proficient. The AAMC core entrustable activities for graduating medical students includes handoffs as a milestone, but no controlled studies with students have assessed the impact of training in handoff skills. The purpose of this study was to assess the impact of an educational intervention to improve third-year medical student handoff skills, the durability of learned skills into the fourth year, and the transfer of skills from the simulated setting to the clinical environment. Trained evaluators used standardized patient cases and an observation tool to assess verbal handoff skills immediately post intervention and during the student's fourth-year acting internship. Students were also observed doing real time sign-outs during their acting internship. Evaluators assessed untrained control students using a standardized case and performing a real-time sign-out. Intervention students mean score demonstrated improvement in handoff skills immediately after the workshop (2.6-3.8; p < 0.0001) that persisted into their fourth year acting internship when compared to baseline performance (3.9-3.5; p = 0.06) and to untrained control students (3.5 vs. 2.5; p < 0.001, d = 1.2). Intervention students evaluated in the clinical setting also scored higher than control students when assessed doing real-time handoffs (3.8 vs. 3.3; p = 0.032, d = 0.71). These findings should be useful to others considering introducing handoff teaching in the undergraduate medical curriculum in preparation for post-graduate medical training. Trial Registration Number NCT02217241.

Medical school handoff education improves postgraduate trainee performance and confidence

OBJECTIVES

Determine postgraduate first-year (PGY-1) trainees ability to perform patient care handoffs and associated medical school training.

METHODS

About 173 incoming PGY-1 trainees completed an OSCE handoff station and a survey eliciting their training and confidence in conducting handoffs. Independent t-tests compared OSCE performance of trainees who reported receiving handoff training to those who had not. Analysis of variance examined differences in performance based on prior handoff instruction and across levels of self-assessed abilities, with significance set at p<0.05.

RESULTS

About 35% of trainees reported receiving instruction and 51% reported receiving feedback about their handoff performance in medical school. Mean handoff performance score was 69.5%. Trainees who received instruction or feedback during medical school had higher total and component handoff performance scores (p<0.05); they were also more confident in their handoff abilities (p<0.001). Trainees with higher self-assessed skills and preparedness performed better on the OSCE (p<0.05).

CONCLUSIONS

This study provides evidence that incoming trainees are not well prepared to perform handoffs. However, those who received instruction during medical school perform better and are more confident on standardized performance assessments. Given communication failures lead to uncertainty in patient care and increases in medical errors, medical schools should incorporate handoff training as required instruction.

The effect of resident duty-hours restrictions on internal medicine clerkship experiences: surveys of medical students and clerkship directors

PHENOMENON: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students' and clerkship directors' perceptions of the effects of the 2011 DHR on internal medicine clerkship students' experiences with teaching, feedback and evaluation, and patient care.

APPROACH

Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation.

FINDINGS

Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. INSIGHTS: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student-patient relationship and students' clinical skills acquisition.

Handoff practices in undergraduate medical education

BACKGROUND

Growing data demonstrate that inaccuracies are prevalent in current handoff practices, and that these inaccuracies contribute to medical errors. In response, the Accreditation Council for Graduate Medical Education (ACGME) now requires residency programs to monitor and assess resident competence in handoff communication. Given these changes, undergraduate medical education programs must adapt to these patient safety concerns.

OBJECTIVES

To obtain up-to-date information regarding educational practices for medical students, the authors conducted a national survey of Clerkship Directors in Internal Medicine (CDIM) members.

DESIGN AND PARTICIPANTS

In June 2012, CDIM surveyed its institutional members, representing 121 of 143 Departments of Medicine in the U.S. and Canada. The section on handoffs included 12 questions designed to define the handoff education and practices of third year clerkship and fourth year sub-internship students.

KEY RESULTS

Ninety-nine institutional CDIM members responded (82%). The minority (15%) reported a structured handoff curriculum provided during the internal medicine (IM) core clerkship, and only 37% reported a structured handoff curriculum during the IM sub-internship. Sixty-six percent stated that third year students do not perform handoff activities. However, most respondents (93%) reported that fourth year sub-internship students perform patient handoff activities. Only twenty-six (26%) institutional educators in CDIM believe their current handoff curriculum is adequate.

CONCLUSIONS

Despite the growing literature linking poor handoffs to adverse events, few medical students are taught this competency during medical school. The common practice of allowing untrained sub-interns to perform handoffs as part of a required clerkship raises safety concerns. Evidence-based education programs are needed for handoff training.

(Re)Introducing communication competence to the health professions

Despite the central role that communication skills play in contemporary accounts of effective health care delivery in general, and the communication of medical error specifically, there is no common or consensual core in the health professions regarding the nature of such skills. This lack of consensus reflects, in part, the tendency for disciplines to reinvent concepts and measures without first situating such development in disciplines with more cognate specialization in such concepts. In this essay, an integrative model of communication competence is introduced, along with its theoretical background and rationale. Communication competence is defined as an impression of appropriateness and effectiveness, which is functionally related to individual motivation, knowledge, skills, and contextual facilitators and constraints. Within this conceptualization, error disclosure contexts are utilized to illustrate the heuristic value of the theory, and implications for assessment are suggested. Significance for public healthModels matter, as do the presuppositions that underlie their architecture. Research indicates that judgments of competence moderate outcomes such as satisfaction, trust, understanding, and power-sharing in relationships and in individual encounters. If the outcomes of health care encounters depend on the impression of competence that patients or their family members have of health care professionals, then knowing which specific communicative behaviors contribute to such impressions is not merely important - it is essential. To pursue such a research agenda requires that competence assessment and operationalization becomes better aligned with conceptual assumptions that separate behavioral performance from the judgments of the competence of that performance.