The aim of this study was to explore differences in handover communication between NHS and UK military emergency care settings, and understand how paramedics manage the transition between them. There is a growing body of international literature on handover communication between paramedics and hospital receiving staff, but little is known about handover communication in the UK military (Slope et al, 2019).
Handover communication in the UK military was governed by Clinical Guidelines for Operations: Joint Doctrine Publication (CGO) 999 published by the Ministry of Defence (MoD) in 2013. This publication mandated the use of the MIST (mechanism of injury, injuries or illness, signs and treatment, adult or child, time), which is often referred to as ATMIST to include patient age and time of incident (MoD, 2013: 41), as well as assigned trauma team roles.
Military practices evolved in response to the conflict in Afghanistan, when UK forces were in command of the hospital at Camp Bastion until they withdrew in 2013. Paramedics deployed to Camp Bastion as part of the Medical Emergency Response Team (MERT) and handed patients over to receiving staff at the emergency department (ED) at Camp Bastion Hospital (Thomas, 2014).
Methods
Semi-structured interviews were undertaken with 13 paramedics to explore differences in handover communication between military and civilian practice and to understand the challenges of transitioning between different emergency care settings. The paramedics had experience of working in both environments and had undertaken at least one deployment.
Data were recorded, transcribed and organised using computer-assisted qualitative data analysis software NVIVO 10. The data were coded until saturation had been met according to Fusch and Ness (2015) using Saldana's (2013: 10) cyclical inductive and deductive method. A thematic analysis of the data was then conducted.
Ethical approval was obtained from the University of Southampton ethics committee, the Royal Air Force scientific assessment committee, and the Ministry of Defence Research ethics committee and the study complied with the code of ethics of the World Medical Association (2018), the Declaration of Helsinki.
Results
Initial results indicated that there were differences between handover communication in UK civilian and military emergency care settings. These were around protocols, communication, patient characteristics, training, behaviour, resources, organisational demands and risk factors.
These initial codes were refined into three themes, which emerged around: inconsistencies between handover communication in civilian and military settings; standardisation, which was a common feature of both; and the challenge of transitioning between care settings. There was a degree of crossover between these themes as standardisation affected the differences between emergency care settings, and participants identified aspects of standardisation that made it more difficult to transition between settings.
Differences
The data showed that the biggest difference that participants were concerned about related to the behaviour of NHS hospital receiving workers compared to military staff, and this is consistent with civilian handover literature (Thakore and Morrison, 2001; Jenkin et al, 2007; Dawson et al, 2013). At Camp Bastion, handover was delivered in a silent receiving bay and hospital receiving staff appeared to listen; this was in contrast to the NHS, where participants reported a lack of respectful behaviour, including interruptions and starting tasks associated with patient care while the handover was taking place. One paramedic reported:
‘I'd say 30 seconds is absolutely maximum, the most you're going to talk for, before people aren't going to resist the urge to put the stethoscope in and start attaching leads to the patient.’ (Interview 10)
Participants had a diverse range of suggestions on how to improve handover communication within the NHS but all wished to see an improvement in behaviour among hospital receiving staff during the handover itself.
A significant difference in training between military and civilian emergency care settings was identified. The data indicated that paramedics, as well as other health professionals, undertook extensive high-fidelity training within the military before being deployed to Afghanistan and, consequently, they thought this affected how handover was delivered and how it was received. It was noted that the hospital at Camp Bastion always appeared ready to receive patients and that staff behaviour was positively affected by this. Handovers were met with silence and there were no interruptions; one paramedic thought this was down to training:
‘And each resus bay being manned by people that have been trained through HOSPEX [field hospital simulation] in how to expect an ATMIST, how to deal with a trauma call, so you have your scribe, your nurse one, nurse two, your anaesthetist, and they've all got predetermined positions and it's all disciplined that way.’ (Interview 8)
Participants reported that they had received extensive training on how to deliver the MIST or ATMIST handover (MoD, 2013: 41) from the military and this was not comparable to training received in the NHS. Training on handover communication in the NHS was of the apprentice type and carried out on the job with the support of a mentor rather than high-fidelity pass or fail courses.
Participants demonstrated insight into why there were differences between handover communication in the NHS and the military. In addition to behaviour and training, they listed significant variances including clinical protocols, resources (both staff and infrastructure), organisational hierarchy and mission, as well as patient characteristics and presentations. They understood that it was not appropriate to simply transfer protocols developed in wartime to civilian settings.
It was acknowledged that NHS hospital receiving staff were under a lot of pressure, and that paramedic handover communication was variable. This is consistent with the international literature on communication regarding paramedic handovers that were too long or unfocused (Owen et al, 2009; Bost et al, 2010). This was reported as follows:
‘I think where handover goes wrong is where it becomes a rambling tale. Not everyone likes doing it—I had a crew mate who in five years would never handover in resus because he found it intimidating, didn't like talking in front of all those people and would invariably delve off into mumbling and just try and get away. We just agreed that I did them.’ (Interview 7)
Standardisation
Standardisation in the military focused on the use of the MIST mnemonic mandated by the CGO (MoD, 2013: 41) but this was accompanied by additional, undocumented practices. These additional practices involved leaving the patient outside the hospital during the handover, question- and-answer sessions after the initial MIST handover and a follow-up scribe handover. The scribe is an important member of the trauma team who is responsible for completing the patient's trauma chart. After the initial handover to the trauma team, the MERT team would give a further handover to the scribe to ensure that the clinical information had been captured and personal details were correct. This handover would include information not pertinent to the trauma team but important for the patient, such as kit location.
All participants reported that the MIST handover mnemonic was consistently followed at Camp Bastion and were complimentary about its use:
‘Using that mnemonic, it's a standardised approach that everybody knows. So I think straight away that makes it more helpful because everybody knows the order and the process of what you are going to say, so the expectation is there of how it is going to be worded. And I think it works, it is simplistic in a sense of getting all the information across but without waffling so without irrelevant stuff that you really don't need to know about.’ (Interview 5)
According to the data, this enabled salient pieces of information to be communicated to the hospital receiving team in a timely, efficient manner. However, one participant thought MIST could potentially be ‘dehumanising’ because it reduced the patient to a set of numbers, but this was an isolated view.
The perception among participants was that handover communication in the military was highly standardised. The practice of leaving the patient outside the ED while the handover was delivered inside the hospital is not documented in the CGO. This was introduced because of security concerns and the need to prevent ordnance (such as weapons and explosive materials) from being carried into the hospital. The data suggested that this had a positive effect on handover because hospital receiving staff were not distracted by the presence of a patient—a common theme in handover communication literature (Owen et al, 2009)—and gave paramedics a head start, even though it had been introduced for security reasons and not to benefit handover. The majority of participants thought leaving the patient outside the resuscitation room was beneficial to the handover, but it was not necessary to introduce to this to the NHS because the risk was much lower:
‘I don't think that it would be necessarily required because the reason why it is happening out in theatre is that they are getting sanitised for explosives and things like that—there's not a huge amount of that in the UK. Obviously, I understand that there is some but there is not the same sort of inherent risk what we experienced out in theatre.’ (Interview 13)
One participant thought that patients and their relatives might perceive this as the patient being abandoned, while others were pragmatic about staff shortages in the NHS that would make this impracticable. Not all participants were comfortable with leaving their patients outside the hospital during the handover because they were leaving them with non-medical personnel and many of their patients were in a critical state. There was disagreement to as to whether this constituted a delay in reaching definitive care, and one participant reported always ensuring that a member of the medical team stayed with the patient in case they needed additional analgesia during the search, which involved a log roll. After the handover, paramedics would provide a follow-up handover to the scribe to add any further pertinent information not covered in the MIST handover.
Participants were concerned about what they believed to be a lack of standardisation in the NHS handover compared to the military process, especially around behaviour of hospital receiving staff and the structure of handover itself. The data suggested that different NHS hospitals required their own handover. According to one paramedic:
‘I may go to five different receiving hospitals in a day and they all have different ways of wanting to receive handovers, if they listen at all, and therefore you adapt it.’ (Interview 4)
Participants reported that attempts were being made in NHS trauma hospitals to make handover communication more professional, and it was thought that the return of practitioners from Camp Bastion was influencing civilian practices in a positive way. Five of the participants thought that adopting the MIST handover, adapted for civilian practice, would improve NHS handover and the other eight were divided.
Handover communication in the NHS is standardised and this is driven by the patient report form (PRF). The PRF captures information about the patient such as observations, brief incident narrative, past medical history and patient contact details. However, concern was raised that hospital receiving staff do not consult the PRF, especially when it has been generated electronically—there was suspicion that these were not printed out at all.
The data suggested, though, that these issues might be resolved by training on how to receive as well as the introduction of the MIST mnemonic or at least a version of it adapted for the civilian environment. It was believed that one of the reasons for interruption by NHS hospital receiving staff was that they did not know in what order the information would arrive and whether it would address all of their concerns.
Transition
Four regular paramedics reported that they did not have any problems transitioning from the NHS to military emergency care settings and two spoke of turning on a ‘switch’. Regulars reported difficulty in navigating medical hierarchies within the NHS and not wanting to ‘ruffle feathers’; they believed the military should be seen as experts in trauma care but found it difficult to challenge NHS practice. The two reservists cited problems with rank and hierarchy in the military, which may be because of greater familiarity with the organisational structures of their main employer. This was also true for perceptions of professional autonomy within each type of organisation and feeling able to challenge practice.
Another problem of transition related to patient factors. Participants recalled difficulties around dealing with young adult patients with life-changing injuries and polytrauma on deployment, then returning to civilian practice where patient presentation was considerably different.
However, civilian practice has its advantages, including the diversity of patient presentation, the learning opportunities and the chance to converse informally with patients. Although military deployments involve a degree of risk given the nature of warfare operations, civilian practice is not without its risks. Participants reported different strategies for managing the transition between the settings including spending time with family, working alongside mentors and undertaking bank shifts. It is a limitation of the present study that only paramedics who had managed these transitions successfully are included.
What was most interesting was that both regular and reservist practitioners reported that making the transition from military emergency care settings to the NHS was more difficult than vice versa, and it was the differences between the settings that made this so problematic. While frustration was articulated at the perceived lack of standardisation with NHS handover communication, standardisation was an issue with both emergency care settings.
Discussion
During the conflict, healthcare protocols, including those covering handover communication in emergency care settings, were documented in the CGO (MoD, 2013). This document is being updated but states that health professionals should use the MIST mnemonic when handing over patients in emergency care settings and that handover should take 20–30 seconds (2013: 40). There is no comparable document in the NHS although the National Institute for Health and Care Excellence (NICE) trauma guidelines encourage hospitals to produce their own pre-alert and trauma response guidance (NICE, 2016). The Royal College of Anaesthetists also recommends that EDs have a multidisciplinary trauma team, including a specialist anaesthetist, on standby 24/7, who should gather before patient arrival to ensure adequate briefing and preparation of drugs and equipment (2019: 6).
A literature review by Slope et al (2019) identified papers on handover communication that made reference to the use of MIST or its variants but only two —Evans et al (2010) and Jensen et al (2013) — referred to the military context within which MIST is used. There is an emerging debate within the literature regarding standardisation of handover communication but little awareness of the unique context in which handover communication in military emergency care settings takes place. The conflict in Afghanistan saw the use of improvised explosive devices (NATO, 2015), as well as conventional weapons, and these led to polytraumatic injuries that are not seen in UK civilian practice.
The military casualties seen at Camp Bastion were typically young, healthy men with traumatic injuries who required rapid access to haemorrhage control, life- and limb-saving surgery, and resuscitation. Civilian patients seen in UK hospitals are often older adults presenting with acute medical conditions. Consequently, there are many differences between military and civilian patient characteristics and presentation, and this is relevant when drawing up healthcare protocols to treat them. Organisational mission and culture are significant and directly affect the provision of health services. The military is a command-and-control organisation, tasked with achieving military objectives, while the NHS is a large, bureaucratic organisation with information needs, which delivers government-led healthcare priorities to a diverse civilian population.
The literature on handover communication refers to the MIST handover mnemonic (and its variants) and, in some cases, argues for their adoption in civilian practices (Jenkin et al, 2007; Iedema et al, 2012; Dawson et al, 2013). However, these papers fail to acknowledge the military context within which MIST evolved including the differences between civilian and military healthcare provision or the additional practices that evolved to support MIST in Camp Bastion. The literature on handover communication does not refer to the CGO (2013) or the undocumented practices that evolved to support the MIST handover at Camp Bastion.
Transition was clearly a significant problem for participants and both regulars and reservists found it more difficult to transition from military deployments to NHS settings than vice versa. Lomsky-Feder et al (2008), in their study of Israeli reservists, said that military reservists could be considered ‘transmigrants’ because they made frequent transitions between civilian and military settings. This would apply to regular paramedics in this study because, while they may be employed by the military, they are seconded to work within NHS ambulance trusts. Each time paramedics, whether regular or reservist, make a transition, they must also break and form bonds and establish themselves among the norms and values of a different environment. The experience of working in military emergency care settings changed their expectations and attitudes towards patients and staff.
Participants in this study had all undertaken successful transitions and it is possible that adult transition is a circular process whereby each successful transition builds resilience. It is also possible that unsuccessful transitions may reduce resilience. Resilience has been identified by Clompus (2014) as an important factor in managing psychological stress among paramedics and by MacManus et al (2014) in relation to UK armed forces.
Conclusion
The current study sought to explore the differences in handover communication between NHS and military emergency care settings, and to understand how paramedics manage the transition between these settings. The data showed that there were variances between handover communication in NHS and military emergency care settings and these incorporated three main themes: differences; standardisation; and transition.
The most significant issue under the theme of differences concerned the behaviour of receiving health professionals and paramedics perceived that their handovers were listened to at Camp Bastion in contrast to the NHS. Participants viewed the military handover as highly standardised in contrast to that in the NHS and, while the data showed this was true for the delivery of the MIST mnemonic, there were additional, undocumented practices that supported MIST.
The theme of transition was pertinent to perceptions of difference and standardisation. Theories of these paramedics as transmigrants breaking and remaking bonds (Lomnsky-Feder et al, 2008) can help us understand how to improve the resilience of this unique group of health professionals. It is recommended that further work is undertaken to research how health professionals manage transition between emergency care settings and the differences between handover communication in military and UK civilian settings.
Finally, the international literature on handover communication should acknowledge the military context within which MIST and its variants were developed and the undocumented practices that supported it.