Handing Over: Developing Consistency Across Shifts in Residential and Health Settings

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This book introduces a new way of conducting a handover which allows the workers themselves to see the process from a wider perspective and to gather information in a different way. The major change is that the team coming on shift take charge of the handover rather than the one going off shift. The new shift then interviews the old. The book gives a clear, practical account of this new model and contains many ideas, particularly relating to interviewing skills, which can be used in other aspects of one's work. There are numerous coaching exercises for the individuals and staff teams as well as verbatim examples of the new handover in action.

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1. The Problem of the Traditional Handover

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From contact with a number of people in different parts of the world, in particular Australia, Sweden and the USA, it seems that there is a model of handovers for shift systems which is shared across many countries. Whafs more, people involved in shift systems in these countries all seem to acknowledge that, although their handover system has been more or less the same for many years, it has been a profoundly unsatisfying system. Dissatisfaction arises from the emphasis beingplaced on contentrather than process, which hasoften contributed to staff becoming insular, with a tendency to dwell on the minutiaeoflivingratherthandevelopinganunderstandingof patterns which lead to a more effective form of intervention around the minutiae. It is also easier to unintentionally adopt a ‘blaming’ stance when concentrating on content. For example, if a 15- year old is rude to one of the staff the incident can be addressed all too easily at the content level and lead the member of staff to feel that the only explanation for the young person’s behaviour lies within that young person. Whitehead and Russell (1910) said that every communication has within it a statement and a statement about that statement. (Put another way - what’s the message behind the message) All too often the latter gets forgotten when issues are addressed with residents or patients. Staff can then get caught up in ‘blaming’, not out of any malice, but because they get involved in a ‘cause and effecf pattern and this gets carried across into other shifts at handover.

 

2. The Systemic Handover

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Although this new kind of handover requires different sorts of skills, in particular, interviewing skills, it is in many respects a very simple notion.

Basic Outline of the System

(1) Prior to the new staff coming on shift, the staff presently on duty get the files up to date and make a list, for the new staff, of any administrative/organisational issues. For example, one task for the new shift might be that a nurse should make sure that patient A takes the drugs given to her at 6 p.m. as there is evidence to suggest that she has not been swallowing them.

Another example might be that the young person’s social worker should be telephoned to inform him/her of some issues which emerged during an individual meeting with that young person.

(2) The staff coming on shift meet for 5-10 minutes, briefly to look at files and formulate any ideas to take up when they meet with the staff going off shift. Hypotheses are often formulated at this stage.

(3) The major structural change to the traditional handover is that in this new system the staff coming on take charge of the handover, not the staff going of £ One of the new shift formally interviews the staff going off, using ideas which have come up in the discussion in (2) and ideas, hunches, hypotheses which they already have as a result of being a part of an on-going process of handovers carried out in this way. Other new staff coming on become observers of this interview and will be able, from the different position of being slightly removed, to formulate suggestions that will further enrich the ideas that are brought forth in the interview.

 

3. Some Theoretical Considerations

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I once looked out of my window into the garden below and watched my cat and a dog who regularly visited go through a familiar script. The cat was running down the garden with the dog in pursuit. It was the normal story and, depending on whether you look at it from the cat’s point of view or the dog’s, you might describe it as either “the cat ran so the dog chased it” or “the dog ran so the cat fled”. At the bottom of the garden my cat suddenly stopped. A second or so later the dog also stopped, looking very bewildered. It was as if the dog were saying “come on now, this isn’t in the script - you run, I chase!” In a way, my cat had introduced a difference into the relationship and the dog’s reaction indicated that he had also taken it as receiving news of a difference (Bateson 1973). The relationship between my cat and the dog seemed to change after that, and I couldn’t help but wonder whether change had partly come about because of the difference introduced by the cat. For the most part, I would suggest that we do not change when we are on ‘auto-pilof, we only change when difference is introduced in a way which makes us less certain of the position we hold. Most people do not change if they feel certain about something. This new handover system is a way of introducing a difference which may make a difference in the quality of work between colleagues and their clients.

 

4. Some Ideas Which Have Influenced the Development of the Systemic Handover

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When we have problems we tend to try and look for solutions. Sometimes the attempt at solutions helps maintain the problem. For example, a wife complains that her husband always leaves towels on the bathroom floor. She picks them up, he continues to leave them, she picks them up, and so on. All of us in our lives attempt to find some cohesive balance between the need for stability and and the need for change, for ourselves and for our relationships with other people. Sometimes in our efforts to find solutions thesolution can be perceived as raising a ‘problem’ for someone else. Although the search for solutions can be seen as positive, the danger is that we can fall into a trap of seeing solutions in absolute terms. We get caught up in looking for the ‘right” answer; somewhere out there is the new reality (the solution) waiting to be discovered. The search for what is right, the search for solutions, the search for the correct way, I would suggest, leads into a minefield. If there is no such thing as absolute truth, only different perceptionsof reality, then looking for some form of certainty can be a wasted effort.

 

5. Circular and Reflexive Questions

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The handover interview can use different styles of questioning but the one which has been practised most by the author and colleagues relies heavily on the use of circular and reflexive questioning. These types of question help the interviewer retain a neutral position and introduce new information into the conversation, which introduces possibilities of new kinds of feedback. This makes a difference to the way beliefs about action and behaviours can change, and thus contribute to more effective and constructive kinds of relationships.

Circular questioning helps those being interviewed to move more to an observer position in relation to themselves so they might achieve a way of perceiving themselves differently. The questions use feedback (verbal and non-verbal) from the interviewee and re-introduce it in a way which challenges beliefs held by the interviewee(s). Thiscontinual ‘to-ing and fro-ing’ of feedback is a co-evolving process, which helps the interviewer and interviewee to start to reframe the problem, to have a different perception of reality, and to move towards finding a difference which may make a difference. However, it is important, as Andersen has pointed out, that the interviewer does not introduce too much difference or too little difference. Too much difference - and this is obviously determined by the way the interviewer perceives the way the interview is going - ‘may have a disorganising effect on the system. In such cases, the system often closes itself to those who have tried to implant such a difference’ (Andersen, 1987). A difference too small to be noticed by the recipient will also make no difference to the problem being addressed. The aim is to introduce a difference which is appreciable enough to make recipients less certain of their position, while at the same time remaining engaged with the recipients.

 

Part I: Types of Questions

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This can vary from very unstructured openings such as:

“What is it that you would like to talk about in this handover?”

to more structured beginnings which ask questions about a particular resident or patient, such as:

“What thoughts about the possible explanations for Mr Gray’s outburst on the ward yesterday have you had. ’

Neither of these approaches is better than the other it depends rather on the style of the person handling the interview and their perception of what might be the best way of interviewing the people going off shift’ This will have been influenced by the interviewer’s hunches and hypotheses about the best way of interviewing one’s colleagues, as well as being informed by the hunches, hypotheses and ideas which may have been formulated in the pre-interview session.

Sometimes, particularly after a difficult shift, it is important to let people have some time to get things off their minds. At these times people generally make remarks about content, so one type of question we have found useful to ask at the beginning of an interview is:

 



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