Benefits and Concerns with Educational Handovers

by Elizabeth Sykes, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital-North Mississippi

Most health professional are familiar with hand-off or handover reports which occur at the beginning and end of a shift, when a patient is transferred from one unit to another, or when there is a change in a patient’s condition.  Handovers occur between nurse to nurse, nurse to physician, nurse to a pharmacist, and even from pharmacist to pharmacist.  These handovers occur within and across all disciplines so that patients receive the most appropriate care.  Handovers are very important for patient safety and continuity of care.  It has been shown that poor or inaccurate handovers may lead to delayed and inappropriate treatment, medical errors, and inaccurate assessments and diagnoses.  Perhaps an educational handover between teachers and educational programs can have similar benefits?

An educational handover, the sharing of appropriate learner performance information between teachers and preceptors to support the learner’s ongoing training and development, is a potentially valuable way to support learning over time.¹ In this way, feedback about performance problems can be made based on multiple, longitudinal observations.¹  Benefits of educational handovers may include improved learning through more tailored feedback and support, improvements in a supervisor’s ability to assess learners related to specific competencies, increased assessor accountability, and improved patient safety through the early identification of weak or problematic behaviors.² 

However, not everyone agrees that educational handovers are useful, valuable, or appropriate.  Despite the potential benefits of an educational handover, there are some concerns associated with it.  Informing future teachers or preceptors about potential performance problems may introduce bias into the assessment process and it may lead instructors to treat some learners differently or label them. This could then lead to both the learner and the assessor acting in ways and viewing the learner’s performance through a lens that lines up with prior assessments. In addition, an educational handover may violate a learner’s right to confidentiality and privacy.²

A study performed at McGill University examined the potential bias from an educational handover on workplace-based assessment scores in medical education.  When given handover reports mentioning weaknesses, the hypothesis was that supervisors would provide lower assessment scores and more negative comments than those who did not receive learner reports.  This was a mixed-methods randomized, controlled, experimental study.  All participants viewed two videos of a simulated resident-patient encounter and then assessed the residents’ performance using the mini-Clinical Evaluation Exercise (mini-CEX).  The two videos viewed them in the same order.    The participants were randomized into three groups that differed based on the educational handover condition: no education handover report (control group), educational handover report indicating weaknesses in medical expertise, and educational handover report showing weaknesses in communication.  Participants had to complete a questionnaire that included questions about basic demographic variables (age, gender), clinical and educational variables (specialty, years of experience supervising, years of experience assessing), and mindset.  An analysis of variance was used to compare mean scores, percentages of negative comments, comments focusing on medical expertise, and comments focusing on communication across experimental groups.³

Seventy-two supervisors completed the study with 21 participants in the control group, 21 in the educational handover group indicating weakness in medical expertise, and 30 participants in the group receiving the educational handover indicating communication weaknesses.  No differences were detected in demographic characteristics, rater experience, or mindset across the three groups.  There was no effect of the handover report on assessment scores (F(2, 69) = 0.31, P = 0.74) or percentage of negative comments (F(2, 60) = 0.33, P = 0.72).  However, the participants who received a report indicating communication weakness generated a higher percentage of comments about communication skills than the control group (63% vs. 50%), P = 0.03).³ 

	Control Group (no handover report) n = 21	Medical Expertise Weakness Group n = 21	Communication Weakness Group n = 30
Mean score for Video 1	5.6 (4.9-6.2)	5 (4.2-5.8)	4.9 (4.5-5.4)
Mean score for Video 2	4.8 (4.2-5.4)	5 (4.4-5.6)	4.9 (4.4-5.5)
Mean score for both videos	5.2 (4.6-5.7)	5 (4.4-5.6)	4.9 (4.5-5.3)

This study suggests that an educational handover can lead to more targeted feedback without influencing scores.  Further studies are needed to examine the influence of reports of various performance levels, areas of weakness, and learner behaviors.³ 

Competency-based medical education (CBME) is becoming the cornerstone of medical education programs.  But the transition from undergraduate medical education to graduate medical education is not a smooth process.  It has been suggested that an educational handover at the end of medical school might help with this transition and would help students become more prepared to care of patients.  The Medical Student Performance Evaluation (MSPE) is submitted in early October each year, and there is very little information provided about the final year of medical school.  In April 2018, the American Medical Association’s Accelerating Change in Medical Education consortium developed five recommendations for developing an educational handover that would be provided to residency programs at the end of medical school.  The 5 recommendations are: (1) The purpose of the educational handover is to provide performance data to guide continued improvement in the learner’s ability and performance, (2) the process used to create an education handover should be philosophically and practically aligned with the learner’s continuous improvement, (3) the educational handover should be learner-driven with a focus on individualized learning plans that are co-produced by the learner and his/her coach or advisor, (4) the transfer of information within an educational handover should be done in a standardized format, and (5) together, medical schools and residency programs must invest inadequate infrastructure to support learner improvement.

Despite these recommendations, there are still challenges with educational handovers between educational programs.  Medical schools would have to develop a curriculum for educational handovers that focuses on assessing individuals' performance.  These should include authentic workplace-based assessments coupled with a formative feedback process.  The Family Educational Rights and Privacy Act (FERPA) regulations apply to educational handovers.  Even though medical school graduates transfer from one educational setting to another, FERPA protects the privacy of learners in both contexts.  Thus, any educational handover will need to comply with FERPA.  Medical schools would need to develop a standardized process to support meaningful communication.  Lastly, creating an educational handover should support a successful transition.  Gathering assessments and adjusting each trainee’s experience during the first few months of a residency would be challenging.  But to be truly effective, the content of the educational handover should be used to implement learner-specific curricular modifications.⁵

Health profession educational programs should have some form of handover, but many of them don’t, or they may lack the appropriate framework.⁴  I believe educational handovers would help prepare learners (students and residents) for the next step in their career.  It can provide future preceptors and employers with information about the learners’ past performance and how they should tailor experiences to help address potential weaknesses.  Educational handovers may lead to some bias, but I believe with appropriate training, preceptors and residency program directors can learn to appropriately use this information to address learner needs. 

References 

1. Guidelines for Educational Handover in Competence by Design. Royal College Committee on Specialty Education: 2018 May 
2. (Gumuchian ST, Pal NE, Young M, Danoff D, Plotnick LH, Cummings BA, et al. Learner handover: Perspectives and recommendations from the front-line. Perspect Med Educ. 2020;9:294-301. 
3. Dory V, Danoff D, Plotnick LH, Cummings BA, Gomez-Garibello C, Pal NE, et al. Does Education Handover Influence Subsequent Assessment? Acad Med. 2021;96:118-125.
4. Gordon M, Hill E, Stojan JN, Daniel M. Educational Interventions to Improve Handover in Health Care:  An Updated Systematic Review. Acad Med. 2018;93(8):1234-1244. 
5. Morgan HK, Mejicano GC, Skochelak S, Lomis K, Hawkins R, Tunkel AR, et al. A Responsible Educational Handover: Improving Communication to Improve Learning. Acad Med. 2020;95:194-199.