Nursing handovers

Please note: We are using the word ‘patient’ throughout this document, but acknowledge that in different care settings, a range of terminology is used. For the purposes of this document, ‘patient’ refers to the ‘people in our care’.

The National Patient Safety Agency defines handover as "the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis" (British Medical Association 2004).

Handover is completed at every change of staff. It involves sharing information that is critical in the patient journey. Nurses are usually introduced to handover as students during their clinical placements. In some areas, there is no formal teaching, training or a syllabus for learning about handover. This means that the structure, method and delivery can vary significantly across the UK.

As nurses, we all have a responsibility to take and give nursing handovers. We do it every time we go on duty, and as it is such a familiar task it's easy to become complacent about it. However, the handover of care is a safety-critical task. Patient safety is directly impacted when it is not delivered effectively. There have been several patient safety incidents across the country where care has been sub-standard due to ineffective handover of information. This should remind us of the weight of our responsibility in handover.

Following a serious patient safety incident, the Healthcare Safety Investigation Branch (HSIB) completed an investigation identifying patient safety concerns about the handover of safety-critical information. The report found several gaps identified in the handover of patient information between health professionals (HSIB 2023).

These included: 

• concerns about confidentiality when displaying patient information on boards or digital dashboards
• difficulty accessing clinical digital systems due to hardware issues, which results in using paper-based systems for critical information
• clinical staff not always being able to access critical information to support decision-making in emergencies.

The purpose of the investigation was to improve patient safety by applying the learning from a tragic incident. As a result, the HSSIB made several recommendations. One of recommendations was for us, here at the Royal College of Nursing (RCN), to develop guidance for nursing handovers with consideration of organisation, content, environment and technology.

The aim of developing and using these guidelines and principles is to support a more standardised approach to the delivery and development of nursing handover. This includes principles for safe and effective handover, which can be adapted to suit all care environments. 

Nurse handover transfers care from one nurse to another nurse or health and social care professional. Handover is a vehicle for communicating all relevant information about a patient’s care.

Bad handovers across every clinical setting can increase the risk of patient harm (a ‘sentinel’ event). A good handover structure and process can reduce the risk of patient harm, improve teamwork and morale and ensure the effective transfer of information overall.

There are different types of handovers:

• nurse to nurse
• nurse to another professional
• routine handover of the previous shift
• escalation of deterioration 
• permanent transfer of care to another unit. 

These all require effective communication between health care teams, acknowledging that clinical environments have become more complex (Sherman 2011). This is more likely since the COVID-19 pandemic, as people are living with more long-term conditions. It remains a core part of the Nursing and Midwifery Council (NMC) Code that nurses ‘share information to identify and reduce risk’, which is a fundamental basis of safe and effective handover.

Guidelines should provide a structure and process for the delivery of handover. This requires organisational and local leadership to implement and embed this process at a service level. Human factors will always influence the success of any standardised process; however, it is crucial to choose a process. The National Institute for Clinical Excellence (NICE, 2018) recommends the use of the ‘Situation, Background, Assessment and Recommendation tool (SBAR) to facilitate handover between transferring and receiving teams.

We have developed the following information and advice to help you plan, develop, deliver and improve safety-critical handovers of care. It is intended for use within the UK, but practices may vary in each country and outside the UK. While every effort has been made to ensure we provide accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used. This guidance advocates a person-centred approach to handover.

There will always be human factors in every safety-critical nursing task. This guidance will not remove this individual autonomy, but it will support a structured approach to the delivery of handover. As a result, there are elements within this guidance which will be more relevant to some clinical areas. When planning a structured handover, you should consider the needs of the organisation and service and the skill sets of the staff working within them.

Alongside the principles, there are some key knowledge, skills and behaviours which can be incorporated into training at local, regional and in higher education levels. Additionally, it is important we support student nurses and newly qualified nurses to triage and prioritise the safety critical information when delivering handovers. 

Every handover should start with an update on a patient’s current situation. Background information is vital when the handover is to agency staff, new starters or just to re-cap where a person is on their care journey. As nurses, we are continually assessing our patients, and sometimes, it is just as important to hand over a visual assessment as it is a formal assessment tool. Being able to pass on recommendations is a helpful way of closing any gaps in care when a shift has had unexpected events or emergencies, and some routine tasks have not been completed. 

Nursing staff should consider the benefits and limitations of involving people in their care in handover and use positive, dignified and protective language at all times when delivering handover of care. For example, some people may want to be involved in handover so they can understand their care needs and plans and can collaborate with nursing staff to achieve care goals. However, for some people, handover may cause distress as they may not understand the information being said about them, which can be both confusing and frightening.

When considering what overarching principles underpin handover, four areas have been identified as crucial areas for consideration and development within the handover process. These can be used to frame a handover process and identify the skills and training needs of those staff required to undertake one. The principles below provide a ‘shopping list’ approach for organisational change and can be used to adapt existing processes and/or create new ones. It may also identify areas for improvement within a service.

A structure is necessary in the successful delivery of information. The 4 areas of handover identified below form the basis for the principles for safe effective handover of critical information about a person's care. They provide a set of overarching principles to support the development and delivery of handover templates in specific clinical areas. 

Our guidance provides more detail about the level of knowledge, skills and behaviour required to work safely within these principles. This can be used to support the development of a structured handover process. It can also help identify areas for improvement (where there is not one already) and support organisations with structured handover templates and proformas. 

The following four areas have all been identified as being fundamental to the handover process:

Leadership and process

• Responsibility and accountability - including delegation of tasks.
• Use of a mnemonic, such as SBAR.
• Information transfer - how to prioritise safety-critical information.
• Escalation and urgent situations.
• Clinical leadership awareness – shift lead/ nurse in charge.
• Time is allocated during shift changeover for effective handover of information.
• Awareness of environment – bedside handover or office based - and how this impacts the patient.

Clinical best practice

• Structure: Use of a template.
• Data set: This will change depending on the clinical setting.
• Statutory/legislative considerations: For example, Mental Health Act, Mental Capacity Act and Deprivation of Liberty Safeguards.
• Person-centred: Always consider the person’s wishes, dignity, and respect, even when they cannot articulate their wishes at the time of care delivery.
• Environment: Bedside handover or office-based? When planning where to conduct the handover, it is essential to consider what is best for the person and the service.

Communication

• Verbal and written standards in line with local regional and national policy and professional code – NMC.
• Effective communication to ensure transfer of complex clinical information.
• Interpretation of clinical information - how do nurses prioritise tasks upon receipt of handover?
• Objective communication.
• Digital informatics.

Education

• Syllabus topic within higher education and across all nurse and nurse associate courses.
• Induction packages to ensure local proformas and standards are known and understood.
• Record keeping - NMC and local policy.
• Technology to support and facilitate handover, record keeping and information sharing.
• Tiering and triaging information – different clinical areas will have different priorities which need to be assessed at a service level. 

Knowledge, skills and behaviours

 

Principles for handover

1. Responsibility and accountability. 
2. Use of a mnemonic such as SBAR.
3. Information transfer.
4. Escalation and urgent situations.
5. Clinical leadership awareness - shift lead/ nurse in charge. 

Knowledge

• Responsibility – who is responsible for completing documentation for handover? if other staff have completed elements of care understand why gaining assurance from them is important.
• Who leads the handover and who is receiving the handover – is the handover to another colleague on the same unit, or are you transferring care to another unit or service?
• Are you transferring care to another unit, healthcare, social care or non-health related service? 
• When the handover is a routine transfer of care at the end of a shift be able to understand what you need to handover.
• When you are transferring care to another unit or service be able to understand all additional specific information which needs to be handed over.
• Understanding and identification of what information needs to be prioritised.
• Understanding of the process of transferring information.
• Understand and utilise the process and proforma within your area of practice to focus your thoughts and help prioritise pertinent information for example the SBAR.

Skills:

• Ability to gain and maintain attention of staff receiving handover even when the environment is busy.
• Communication skills to deliver clear, concise, accurate and contemporary information about the people in your care.
• Ability to triage and prioritise information and task allocation.
• Ability to differentiate between routine handover and escalation due to a deterioration in physical or mental health – think about unusual events and how who do you need to tell about them.
• Ability to manage and coordinate a sudden deterioration, including handing over information to colleagues and emergency services.
• Ability to assess staff receiving handover and if they require any additional resources or information to be able to take a safe handover.
• When taking handover, be able to ask questions if you are not clear on any aspect of the information you have been given.

Behaviour:

• Be able to deliver clinical information in a calm and efficient manner.
• Always use correct and respectful language.  
• Ensure junior staff, student nurses or agency staff are supported to learn the process and procedures of handover.

Principles for handover

1. Structure.
2. Data set - this will change depending on clinical setting.
3. Statutory duty - MHA, MCA and DoLS.
4. Person centred.
5. Environment - bedside handover or office based. 

Knowledge

• Know the process and procedure for handover in your clinical/care area, including any mnemonic or completing a proforma.
• Understand the rationale for a structure and ensure that the structure is adhered to at every handover of care. 
• Understand and utilise the principles of person-centred and/or person-led care when delivering handover. 
• Understand the different environments for delivering handover – bedside, board, office and how these may influence the transfer of information and patient care – it is important essential to dynamically risk assess the best environment for handover depending on patient/person needs and service.  
• Understand the statutory duties of legislation in your country of practice, for example, the Mental Health Act, The Care Act, The Mental Capacity Act, The Incapacity Act, The Human Rights Act, Mental Health Order (NI) and any relevant health or capacity legislation in your country of practice and how any restrictions or care pertaining to these acts is communicated at handover.

Skills

• Ability to assess the environment and patient need – where is the best place for handover – some people may prefer a bedside handover so they are included in the process, but for some people, this may prove distressing and an office-based handover is more suitable - assess each patient and what will be best for them.
• Ability to triage and prioritise which data is vital and where it should sit within the handover process.
• Be agile enough to assess, prioritise and include additional or extraordinary information at handover when required. 
• Understand how to sensitively transfer information pertaining to statutory responsibilities while maintaining patient dignity and respect. 
• Be able to identify when there are new staff who may be receiving handover of care for the first time (student nurses, new staff, agency staff) and be able to give a more detailed history to support their induction to the people they will be caring for. 

Behaviour

• Be able to maintain a respectful dialogue when referring to all people in your care. 
• Be able to acknowledge any judgement or prejudice towards anyone in your care and professionally detach from those feelings to deliver factual and accurate information about their care.

Principles for handover

1. Verbal and written standards in line with local regional and national policy and professional code - NMC.
2. Effective communication to ensure transfer of complex clinical information.
3. Interpretation of clinical information - how do nurses prioritise tasks upon receipt of handover.
4. Objective communication.
5. Digital informatics. 

Knowledge

• Understand the policy and procedures within your area of work and how these work with your professional code of conduct. 
• Be aware of communication methods, including verbal, non-verbal, and written communication. 
• When using nursing jargon or acronyms, check that all staff giving and receiving handovers are aware of their meaning and avoid slang or local sayings. 
• Be able to interpret clinical information such as Early Warning Scores (EWS) and ensure this interpretation is incorporated into your handover and recommendations for care. 

Skills

• Be objective in your communication and handover; be factual and accurate. 
• Where you are using clinical judgement and/or clinical decision making, ensure you are working within your sphere of competence. 
• Competent use of any technology used for recording observations, giving handovers and making a record of care. 

Behaviour

• Be able to maintain an even tone and pace of voice when delivering verbal information.  
• Be aware of your body language and non-verbal cues when delivering handover information. 
• Check that people have understood your handover without appearing to be condescending or demeaning. 
• Minimise and manage noise levels and disruption.

Principles for handover

1. Syllabus topic within higher education and across all nurse and nurse associate courses.
2. Induction packages to ensure local proformas and standards are known and understood.
3. Record keeping - NMC and local policy. 

Knowledge

• Ensure that there is an adequate proforma, policy, standard operating policy and/or procedure for safe and effective handover. 
• Embed training about the importance of handover in all induction packages. 
• Consider the possibility of embedding the importance of handover in higher education syllabuses for all student nurses and student nurse associates. 
• Awareness of why handover is a vital component of nursing care. 

Skills

• Be able to teach people in your area of practice how to deliver a safe handover and record it.
• Maintain accurate records in line with professional standards and policy.
• Competent record-keeping in line with local policy and your professional standards as outlined in your code of practice. 

Behaviour

• Be positive about the process and importance of handover.
• Role model good handover, use template and promote positive person-centred language.

There is recognition that the SBAR approach can shape how you think about what safety-critical information you need for an effective handover. Evidence has highlighted how this process has proved successful in routine handover and the escalation of clinical deterioration and safe transfer of people to different clinical settings when taking place over the phone. This may include speaking with a senior nurse, doctor or emergency service. It can also be used for escalation to support a handover when a person’s condition has changed and is deteriorating.  As a result, the guidance looks at incorporating the SBAR tool approach into local proformas and templates for structured and routine handovers. 

The SBAR template can form a valuable basis for a handover proforma and is widely advocated in health care services. The templates below provide ideas, examples, statements and suggestions for how the SBAR process can be used for nursing handover of care. The level and frequency of these routine observations will differ from service to service.  

We acknowledge it is impossible to include every scenario you may encounter within the handover, and you will need to add considerations specific to your area of practice.  

What to consider

Escalation

• Hello my name is…
• I work at…
• I am calling about…
• I am concerned because…
• I have taken the following actions…

Routine

• During shift today this has happened…
• The current presentation/ condition and care delivery is as follows…
• Nutrition, hydration, mobility and other activities of daily living…
• Medication given as per chart – be specific about ‘when required’ or PRN medication.
• Person identification – evidence based – soft words.

What to consider

Escalation - acute

• Patient was admitted on… with… (date and presenting complaint).
• They have had… (treatment/diagnostics/operation/investigation).
• Their condition has changed in the last…
• Their last set of observations were…
• Patient’s usual condition is… (think ACVPU).

Escalation - community

• Person has been stable on the unit/in the home/in this service for…
• They have… (diagnosis including care needs).
• Their baseline function is… (think ACVPU observations, mobility, and cognition).
• Their presentation has changed in the last…
• Their advanced care plan states…

Routine

• Person was admitted on/moved in on… with…/ resident has been stable on unit for...
• They were admitted with/their diagnosis is...
• Discharge plans/social care needs/visiting status.
• Care plans are…
• Legal considerations and other safeguards on the ward/unit/service (think MHA/MCA/DoLS/Safeguarding).
• Nutrition and hydration today was…
• Person has slept for X hours during the shift.

What to consider

Escalation

• My objective assessment is… (includes observations, physical assessment etc).
• My concerns are… because of…
• My actions so far are…

Or

• I am not sure what the problem is but the patient is visibly deteriorating and/or I am really worried.

Routine

• I think the patient has… (been settled/confused/any other behaviour).
• I have… (delivered all care as planned/administered additional medication/changed dressings/supported in meaningful activity).
• Any concerns however small are…

What to consider

Escalation - acute

• I need you to… (come and review the patient in the next X mins).
• What do I need to do in the meantime? (Stop fluids/push fluids/repeat obs/bleep other team).

Escalation – community

• I need you to… (book GP appointment/issue repeat or anticipatory prescription/refer to speciality service/advise about ED attendance).
• I recommend you increase observations (think NEWS and also visual/arms reach/1:1).
• Administer PRN medication (suppositories/dressing change/sedation).
• If you have any concerns, contact… (manager on call/out of hours service/999).

Routine

• I need you to continue with care plans.
• Continue with routine observations.

• Template design: Find or design a handover template that will work within your unit, service, or organisation. This will provide standardisation, which will support staff when they move from area to area within the organisation and will also prompt all staff to give handovers. A systemised approach to the delivery of handover starts with a template or proforma.  
• Time for handover: Handover of care is a safety-critical task, and time needs to be allocated at shift cross-over for nursing staff to deliver a detailed and safe handover. 
• Place for handover: Consider the people in your care - would they benefit from being involved in their handovers, or would it cause them distress? This can be dynamically assessed by the nursing staff delivering the handover. The needs of the service also must be considered. Where the area is very crowded, busy or big, an office-based handover may be the safest option to ensure the staff receiving the handover can hear and absorb the information given. 
• Information sharing for safety: Consider all information which pertains to person-centred safety planning, including risk of suicide (DHSC link), safeguarding, risk of self-harm, and so on.  
• Debrief after events: When there has been an incident on shift, it is essential for staff involved to be offered the opportunity to have a debrief which can help to minimise the emotional toll of caring.

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Positive Words (safewards.net)

Thanks to the following expert nurses for giving their time and expertise to this resource:  

Rosaline Kelly – RCN Northern Ireland Senior Nurse Professional Practice 

Nicola Davis-Job – RCN Wales Acute Care and Leadership Adviser 

Jacqui Neil – RCN Scotland Senior Nurse, Policy and Professional Practice 

Louise Parker – RCN UK Professional Lead for Long Term Conditions Stephen Jones – RCN UK Professional lead for Mental Health 

Ella Brennan – RCN Development Post for Acute and Emergency Care 

Deb Evans – RCN Development Post Community Nursing 

Ofrah Muflahi – RCN UK Professional Lead for Nursing Support Workers 

Suman Shrestha – RCN UK Professional Lead for Critical Care 

Claire Sutton – RCN Transformational Lead for the Independent Health and Social Care Sector 

Andrea Dauris – Associate Director of Nursing Calderdale and Huddersfield NHS Foundation Trust  

 

This guidance has been written by staff within the RCN, with targeted expert member feedback and advice to steer its development.