Communication & Medicine Clinical handover as an ...

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handover protocol ISBAR by Junior Medical Officers in an Australian public hospital. The clinicians had been trained in ISBAR and were strongly encouraged.
Communication & Medicine Volume 9(3) (2012), 215–227 Copyright © Equinox Publishing Ltd Sheffield http://equinoxpub.com DOI: 10.1558/cam.v9i3.215

Clinical handover as an interactive event: Informational and interactional communication strategies in effective shift-change handovers Suzanne Eggins and Diana Slade University of Technology Sydney, Australia

Abstract Clinical handover – the transfer between clinicians of responsibility and accountability for patients and their care (AMA 2006) – is a pivotal and high-risk communicative event in hospital practice. Studies focusing on critical incidents, mortality, risk and patient harm in hospitals have highlighted ineffective communication – including incomplete and unstructured clinical handovers – as a major contributing factor (NSW Health 2005; ACSQHC 2010). In Australia, as internationally, Health Departments and hospital management have responded by introducing standardised handover communication protocols. This paper problematises one such protocol – the ISBAR tool – and argues that the narrow understanding of communication on which such protocols are based may seriously constrain their ability to shape effective handovers. Based on analysis of audio-recorded shift-change clinical handovers between medical staff, we argue that handover communication must be conceptualised as inherently interactive and that attempts to describe, model and teach handover practice must recognise both informational and interactive communication strategies. By comparing the communicative performance of participants in authentic handover events we identify communication strategies that are more and less likely to lead to an effective handover and demonstrate the importance of focusing close up on communication to improve the quality and safety of healthcare interactions. Keywords: clinical handover; interaction; language/ communication strategies; ISBAR; shift-change; safety

1. Introduction Clinical handover is a pivotal communicative event in medical and nursing hospital practice, occurring at many different times and in a range of settings – at shift changes, between wards, on discharge. The Australian Medical Association (AMA 2006) defines clinical 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.

Estimates suggest that more than seven million handovers occur annually in Australian hospitals (Manias et al. 2008: 37). In Australian public hospitals, most clinical handovers are verbal face-to-face encounters between the outgoing clinician or team and the incoming clinician or team. Scheduled clinical handovers may occur at the patient’s bedside, by the ward whiteboard, in a meeting room, during a ward round, at the nursing station or in a discharge lounge. Many other opportunistic handovers occur in corridors, on the phone outside work hours, over coffee, etc. This paper focuses on face-to-face scheduled handovers between doctors at formal shift changes. Both their frequency and their high-risk status make clinical handovers critically important hospital events and high priority areas for research to improve patient safety. In its guide to improving clinical handover, the Australian Commission for Safety and Quality in Health Care (ACSQHC 2010) notes research by Wong et al. (2008) that identified clinical handover as a ‘high risk scenario for patient safety’, potentially contributing to discontinuity of care, adverse events and malpractice claims. While lack of time and space for handing over and frequent interruptions of clinicians during

216 Suzanne Eggins and Diana Slade handover are identified as contributing to poor handover practice, increasingly it is communication in handover that is receiving attention. There is no doubt that clinicians themselves regard handover communication as problematic. Interviews by Arora et al. (2005) of first-year resident physicians about adverse events and near misses related to handover found that communication was a factor in all incidents. As discourse analysts, our research into the institutional discourse of clinical handover is applied and pragmatic, driven by the questions: ‘Do particular interactional practices expedite or improve the effectiveness of particular activities and, if so, are there downside costs?’ (Heritage and Clayman 2010:19). In this paper we present authentic handover transcripts to show the interdependence of interactional and informational dimensions in achieving effective handovers and to suggest strategies clinicians could use to hand over more effectively. We argue that major improvements in handover communication will not occur until handover is conceptualised as inherently interactive and the consequences of that interactivity are allowed to inform handover processes, practices, protocols and training.

2. Background The communication problem commonly identified with clinical handovers that has received most attention is that information is incomplete and/or unstructured. An Australian study of emergency department handovers in 2007 that found that in 15.4% of cases ‘not all required information was transferred, resulting in adverse events’ (Ye et al. 2007). Arora et al. (2005: 11) found that ‘omitted content (such as medications, active problems, pending tests) or failure-prone communication processes (such as lack of face-to-face discussion)’ made it difficult for incoming clinicians to take over care of patients. A survey of Australian doctors by Bomba and Prakash (2005) found that 95% did not believe that there were formal or set procedures for handover and McFetridge et al. (2007: 261) reported that ‘there was no structured and consistent approach to how handovers actually occurred’ in nursing handovers from the emergency department to ICU. In Australia, as internationally, one reaction has been for Health Departments and hospital management to seek to standardise handover communication, often by encouraging or compelling clinicians to follow a standard communication protocol when

handing over. Use of the IS(O)BAR protocol is becoming increasingly widespread, supported by explicit documentation and training (e.g. NSW Health 2010) (see Figure 1 for an explanation of this protocol mnemonic). I

Introduce (yourself and/or the patient)

S

Situation (give the patient’s age and status)

B

Background (explain the presenting problem)

A

Assessment (state the patient’s current condition, risks, needs)

R

Recommendations for patient care (outline your treatment plan)

Figure 1. The ISBAR communication protocol for clinical handover

From a clinical point of view, protocols like ISBAR are designed to help clinicians include and order information logically. However, our data suggests that the compliance rate with ISBAR is very low. While complex cultural and institutional factors contribute, a linguistic analysis also suggests potential reasons for reluctant uptake. From a linguistic point of view, structures like ISBAR represent attempts to establish a staged structure for the clinical handover genre, where ‘genre’ refers to a recognised and recurrent social activity achieved collaboratively through language (Eggins 2004: 54–58; Yates and Orlikoswki 1992). However, for linguists a protocol like ISBAR has two immediately apparent limitations: 1. It is a monologic structure that specifies only the contribution of the person giving the handover. No mention is made of the role or possible contributions of those receiving the handover, although the overwhelming majority of clinical handovers are delivered interactively, to recipients who are present at the event. 2. It focuses only on the informational content of the handover, although since the 1960s sociologists and discourse analysts have been demonstrating that any interactive event requires also the management of the interactive dimensions of communication (e.g. Garfinkel 1967; Schegloff and Sacks 1974; Sacks et al. 1974; Heritage and Clayman 2010).

We note Patterson’s reservations when she warns that ‘the primary benefit of standardising handovers will be a new way to blame “sharp end” providers for failing to communicate critical information during the course of care’ (Patterson 2007: 5). However, we suggest that the problem may not lie primarily with the focus on standardisation itself, which does appear to offer benefits to novice clinicians needing ways to manage the complex informational dimension of handover (McGregor et al. 2011). Rather, what may fatally dull the impact of standardisation efforts is, we suggest, their narrow view that communication involves only the monologic transmission of information. Other researchers have also suggested that the complexity of clinical handover communication may demand more interactive and contextually flexible strategies. Patterson et al.’s (2004) study of handovers in other high-risk workplaces (nuclear power plants, NASA, ambulance dispatch centres) proposed a range of interactive communication strategies that could be used to improve the effectiveness of handovers. Strategies included: encourage interactive questioning during handovers; limit interruptions; allow topics to be initiated by incoming staff and include a read-back to check information was accurately received. Similarly, Behara et al. (2005) argue that the heterogeneity of clinical handovers means that attempts to impose one-size-fits-all structures may fail. Such studies highlight the role of interactive communicative strategies by all handover participants and the need to understand key contextual dimensions that impact on handover. However, they do not present ‘raw’ interactive data to ground their claims either about what does go on in handovers or about what communicative strategies should be encouraged. As linguists, we offer an approach that starts with authentic handover interactions and seeks to identify the language strategies that do and do not work for the participants.

3. Methodology Our data was collected as a part of a one-year pilot project by a team from the University of Technology Sydney (UTS). The project was funded by a state Health Department and UTS to investigate the uptake and effectiveness of the communication handover protocol ISBAR by Junior Medical Officers in an Australian public hospital. The clinicians had been trained in ISBAR and were strongly encouraged

Clinical handover as an interactive event 217 to use it at all handovers. Figure 2 sets out key information about the group studied. For a full report on the project’s mixed qualitative methodology and outcomes, see McGregor et al. 2011. Data collection site:

Campbelltown Hospital

Participants:

Medical registrar and Junior Medical Officers

Event:

Morning medical handover (from night shift to day staff )

Event location:

Usually held in staff room

Event focus:

Handover focuses on patients who have needed attention during the night shift or who need following up by the day shift

Figure 2. Summary of handovers studied in the ISBAR clinical handover communication project

The project included the audio-recording of ten shiftchange handover events, which were then transcribed and de-identified. Each event involved several doctors handing over between four and eight patients to the incoming team. In the following sections we present and discuss two extracts from one of the morning shift hand­ overs. These extracts are representative of the type and range of communicative behaviours in the handover corpus. They also show contrasting ways of managing the handover interaction, and are therefore useful in shedding light on communicative behaviours that both assist and detract from the effectiveness of clinical handovers. Figure 3 provides a key to the transcription conventions and the participants. Our linguistic approach is influenced by ethnomethodology’s focus on how people make shared meanings through interaction (Garfinkel 1967, 2006). We share with conversation analysis the commitment to study authentic data collected in real interactive contexts (Sacks 1984, 1992) and to recognise that each speaker’s talk creates the context within which the next speaker’s talk makes sense (Schegloff and Sacks 1974: 296). We are therefore oriented to exploring discourse behaviours by which participants jointly achieve the continuity or discontinuity of interaction. We also approach interaction as meaning ful work. We are interested in how participants collaborate to direct attention and effort to manage

218 Suzanne Eggins and Diana Slade Key to transcription conventions & participants

...

short hesitation



aside or re-start

==

overlap starts

( )

inaudible speech or (transcriber’s guess)

[

]

contextual information

Key to participants

OUT-D1

medical registrar; male, Indian-English accent, outgoing shift, hands over 4 patients. Called Tamu in transcript.

All names have been changed

D2

Junior Medical Officer; female, Irish accent, incoming shift. Called Jenny in transcript.

D3

Junior Medical Officer; female, Australian English, incoming shift

OUT-D4

Junior Medical Officer; male, Australian accent, outgoing shift, hands over 1 patient. Called Hal in transcript.

D5

Junior Medical Officer; female, Asian accent, incoming shift

D6

Junior Medical Officer; male, indeterminate accent, incoming shift

Figure 3. Key to transcription conventions and participants

turn-taking conventions and each other’s expectations in order to exchange meanings through talk (Sacks et al. 1974; Schegloff 1981; Heritage and Clayman 2010). Finally, we are influenced by the systemic functional linguistic model of language as a semiotic system that is organised to enable us to exchange both and interpersonal meanings – meanings about the interaction and our relationships with those we are interacting with – and ideational meanings – content meanings (Halliday and Matthiessen 2004; Eggins 2004). In applying systemic linguistics in institutional contexts, we find it useful to re-gloss these types of meaning with the more transparent terms of ‘interactional’ and ‘informational’. We are also influenced by existing research on clinical handover and our earlier research into communication in hospital emergency departments, both of which note that hospital communication is characterised by frequent interruptions, competing demands for clinicians’ attention, high ambient noise levels and extreme time pressure. In audio recorded interactions between clinicians and patients

in emergency departments, we also often found marked differences between the communicative behaviour of senior and junior clinicians (Slade et al. 2011). The applied motivation for our work on clinical handover means we wish to offer clinicians and hospital management relevant recommendations that can lead to achievable improvements in handover communication.

4. Managing information in interaction effectively The transcript below is from a shift handover by two outgoing nightshift doctors. OUT-D1 is a medical registrar with several years’ post-graduate experience. OUT-D4 is a Junior Medical Officer with limited hospital experience. They hand over to four incoming day shift doctors (D2, D3, D5, D6). The complete event lasts 19 minutes. Extract 1 is the first 3 minutes 25 seconds of the interaction.



Clinical handover as an interactive event 219

Extract 1 Turn

Speaker

to find out why she’s on methotrexate. Um the other thing … because she’s confused, um she did not have any temperature, the white cell and CRP was normal I did not give any antibiotic but then I was talking to … ah, Dr Collins this morning, quarter to 7 or something, and she said to start on ampicillin, she (needs a) LP.

Text [one doctor – D3 – is on the phone, concurrent conversation goes on for some time. Not transcribed in full.]

1

OUT-D1

Okay, ready, Jenny?

2

D2

Yep …. 24.

3

OUT-D1

24 … that’s bad … Ah, you will probably need some help from some other people who’s not that busy, maybe …==

4

[D3]

[speaking on phone]== Oh. Oh, right, OK.

5

OUT-D1

==give you a hand. Because 24 is too much==

6

D2

==I have four consults ( ) … it’s Monday.

7

OUT-D1

Right. OK. Look, um, alright, I’ll start with, um, um, (Maria Sostway) name. She’s a 51-year-old lady, um, who has got diagnosis of um, MS since 1990. And also epileptic since she was, um, um, during her teen age. Um she’s normally looked after by the husband at home for the last 17 years or so. Note to Dr Blue, who manages the MS. Um, comes in here … last … umm, flare up was two years ago or something. Um so comes in here with um being unwell for the last one month – gradual decline – and was very confused in the last four or five days. Just generally unwell, full oral intake. Umm, she also has got a ileal conduit. She’s just recently been treated for a possible UTI by the GP. There was nothing to suggest that she has got a UTI, or any other infection. So confusion … not sure where it is coming from. She’s on lots of … um, you know, this, um, medication, like gabapentin and all the anti-epileptics that could have been causing it. She’s on carbamazepine but that level is normal.==

8

D2

==The level’s normal?==

9

OUT-D1

==Sorry?

10

D2

The level’s normal?

11

OUT-D1

The level is normal last night, so … Basically it could be – and she’s on methotrexate umm, whether it’s for MS or something else, I’m not entirely sure, so we’ll probably have to chase some letters from Dr Blue

12

D2

She hasn’t had the LP yet?

13

OUT-D1

She hasn’t had the LP yet. She was confused so we need to get==

14

D2

==She’s still down in (in the DUC) is she?==

15

OUT-D1

==No no, she is, she’s up in the ward. I … no, I … it was not in my plan to==

16

D2

==I know, I know, I just don’t know how I’ll have time to LP someone (during the) day.

17

OUT-D1

And um, yeah, so, um, but in the morning I think there’s the husband needs to consent first, to have the LP done. So … yeah, I couldn’t – I couldn’t get it done. The other thing you could do is just um consent and get it done under the radiology, cause you’re too busy, and then ah, just can be done on the under radiology==

18

D2

==OK, OK ==

19

OUT-D1

You could possibly talk with them first thing in the morning, and then consent, and just ( ). And (talk) to the Radiology Reg and say it is a difficult one. It can be done.

20

[D3]

==Yep, no worries. Thank you very much for that. [concurrent phone conversation ends here]

21

OUT-D1

She’s confu—I mean, the husband needs to actually know about it, and then um consent.

22

D2

So she started on ampicillin but hasn’t had an LP?

23

OUT-D1

She hasn’t had an LP==

24

D2

==But you put her on ampicillin already?

25

OUT-D1

She hasn’t had any dose. =Yeah.

26

D2

==OK. The nurses know not to give it?

27

OUT-D1

No.

28

D2

OK.

29

OUT-D1

Ummm, OK, so, ah, the next one is um … .

220 Suzanne Eggins and Diana Slade Our analysis below focuses on three distinctive features of handover interaction, exemplified in Extract 1. 4.1. Interruptions and absences Mobile phones ring three times in the 19 minutes. One participant, D3, is preoccupied with her mobile for up to 8 of the 19 minutes and plays no role at all throughout Extract 1. Two or more participants seem to have a brief whispered conversation at one point. These interruptions suggest the ambiguous status of shift handover meetings institutionally and individually: is it considered essential or merely desirable for incoming staff to be fully attentive during the handover? 4.2. Differential participation Across the 19 minutes we see very different interactive performances, some that we suggest are effective in achieving the purpose at hand and some that are not. For example, Extract 1 involves just two of the six participants present. The participants’ contributions to the interaction are summarised in Figure 4. Participant

Number of turns Comment on participation taken in event

OUT-D1 61

dominates talk, hands over four patients, long turns

4.3. Differences in handover styles The most striking feature of this data is the contrasting manner in which the two outgoing doctors achieve their handovers. We use the term ‘style’ to capture the clustering of discourse features from both interactional and informational dimensions of meaning. Table 1 captures these key stylistic differences in the two extracts presented in this paper. In Extract 1, turns 7 to 28, we see the registrar OUT-D1’s first handover. Interactionally, OUT-D1 demonstrates clear framing with staging expressions that claim the floor and state the purpose, e.g. T7: Right. OK. Look, um, alright, I’ll start with .... His style of delivery is largely monologic, fluent and confident. He speaks at a pace and with intonation patterns that discourage interruptions. This means he is able to hold the turn to produce multiple-clause turns or monologic ‘chunks’, e.g. T7 is 20 clauses; T11 is 15 clauses. Informationally, we see that OUT-D1 provides a structured presentation of clinical information. Although he does not precisely follow ISBAR he sequences his information in a logical, orderly way: Identification, e.g. T7: (Maria Sostway) name Background, T7: From She’s a 51-year-old lady, um who has got diagnosis of um, MS since 1990 [to] last ... umm, flare up was two years ago or something. Presenting problem, T7: [from] Um so comes in here with um being unwell for the last one month [to] she also has got a ileal conduit.

D2

31

highly interactive with OUT-D1; queries, checks, clarifies, comments

D3

5

‘absent’ for 8 minutes; all turns are minimal reactions

Tentative diagnosis/hypothesis, T7: [from] treated for a possible UTI by the GP [to] all the anti-epileptics that could have been causing it.

OUT-D4 26

short turns; poorly hands over one patient – needs support

Actions needed: information, procedure, T11 she said to start on ampicillin, she [needs a] LP.

D5

becomes engaged only when OUT-D4 starts hand over; but then actively probes and queries

D6

32

24

becomes active when OUT-D4 hands over; but requests/comments are often tangential to handover focus

Figure 4. Different contributions of participants across the 19-minute handover event

Repetition of action needed, T13, T17 Advice on planned procedure/treatment, T17 The other thing you could do [..] under radiology; T20

We might be tempted to conclude that OUT-D1 is proof that if doctors follow an ISBAR-like protocol, they will achieve effective handover. However, if we only considered OUT-D1’s role in the handover, we would miss the absolutely vital point that the handover is achieved interactionally with the close collaboration of D2. D2 works energetically to achieve effective handover, contributing 11 turns to the interaction:



Clinical handover as an interactive event 221

Table 1. Summary of contrasts in handover styles displayed in Extracts 1 and 2 Dimension of handover

Interaction

Speaker(s)

Outgoing doctor

Incoming team

Information

Outgoing doctor

Incoming team

• • • • • • • • •

Feature

Extract 1

Extract 2

Delivery

Assertive, confident, fluent

Hesitant, not confident

Dominant speech act

Makes statements

Asks questions

Turn management

Holds the floor to Loses the floor, proproduce long turns; disduces short turns only courages interruptions

Control and management of pragmatic focus, humour, diversions etc

Loses control – interMaintains control of huaction deteriorates, mour, resists diversions humour intrudes and and keeps on topic topic focus is lost

Framing, staging

Uses explicit markers No explicit framing or Right, OK, I’ll start with staging

Responsiveness

Responds to incoming team’s queries

Unable to resolve team’s queries

Role in interaction

Active in checking, clarifying, confirming

Required to elicit basic information

Status of information

Specific, certain

Vague, tentative

Organisation of information

Logically structured in conventional clinical stages: identification, background, presenting problem, diagnosis, actions, advice

Poorly structured – key information is elicited through questioning by incoming team

Recommendations for incoming team

Gives clear advice, Vague and ambiguous specifies explicit actions on care plan for incoming doctors

Role in information

Do not need to elicit basic information

In turn 8 she checks information given (test results) In turn 10 she repeats the check In turn 12 she seeks clarification of the procedure In turn 14 she seeks clarification of the patient’s location In turn 16 she states a problem with the action she is required to take In turn 18 she acknowledges advice offered by OUT-D1 in T18 In turn 21 she repeats a summative check of information and implications so far In turn 23 she repeats a check of the medication In turn 26 she seeks clarification of OUTD1’s response in 25



Need to elicit basic information

In turn 27 she confirms her satisfaction with the information she has received (and thereby gives implicit permission for OUT-D1 to move on to the next patient).

All OUT-D1’s four handovers unfold in a similar way: with an initial monologic turn from OUT-D1, using a similarly structured information sequence, followed by close interactive questioning from D2 and eventually D6 and D5 as well. We suggest that OUT-D1’s style has both interactional and informational benefits. It allows him to hold the floor long enough to deliver key parcels of clinical information, while giving the incoming team the space to follow up the shared topic. Informationally, the structured style means OUT-D1 selects and presents clinical information that the incoming team

222 Suzanne Eggins and Diana Slade can check, confirm and feel confident to act on. In short, OUT-D1’s style demonstrates an effective use of the interactive context to collaboratively but concisely negotiate clinical information so that the incoming doctors are satisfied they have what they need to assume responsibility for the patient’s care.

5. Poor interactional management and its impact on information Compare the well-managed and highly negotiated handover in Extract 1 to the handover by OUT-D4, the Junior Medical Officer. This begins 14 minutes 39 seconds into the event, in Extract 2.

141

D5

That doesn’t make sense.

142

D6

Old people walking around at night

143

D5

No, but he’s – he doesn’t have that== [background noise – people walking, chatting in corridor]

144

OUT-D4

He doesn’t, he’s from a home, ==isn’t he?

145

D5

==Yeah. And he’s oriented to ==( )

146

OUT-D4

Yeah. It’s a strange delirium. You can converse with him, but ==then he’ll just distract and start doing other things.

147

D5

==[inaudible comments in response to OUT-D4] Yeah, but he’s really distracted. Yeah.

148

OUT-D4

Um, but, ah, yeah, so I had to give him 0.5 valproate last night.

149

D5

That’s fine. Did he settle down with that?

150

OUT-D4

He did, but then woke up at about 5 o’clock, clambered out of bed and had a fall.

Extract 2 128

OUT-D1

OK. That’s [it] from me, I think Hal has got one, for um

129

OUT-D4

Dr King. Is that a medical ( )?

130

D2, D6

Yes.

[D3

talking on phone—leaves the room. Door opens and closes]

131

OUT-D4

Um, so Mr Van den Gast==

151

D5

Oh.

132

D2

==Oh==

152

OUT-D4

133

OUT-D4

==Yeah. He was apparently giving trouble last night, umm, as in the night before with his some delirium, like pulling at IV lines and there’s SPC and everything like that. Having trouble last night as well, umm

But nothing, nothing too obvious was damaged [laughs], ummm, but er ... just wondering, like as in, it’s just his infection causing the delirium, it’s … his electrolytes…==

153

D5

==Yeah, well he’s got a … he’s got a really complicated urological, um, background, ( ) and it’s query urosepsis so you know really they need to get on and unblock it or drain it ( )

154

D6

Do you know if the urology registrar saw him last night? If there was any notes?

155

OUT-D4

==Well … no, but when I saw him this morning there was a catheter inserted, so possibly he did get seen by a urologist.

156

D5

You mean that … no, he’s already got a SPC.

157

OUT-D4

No, no, no, a urethral, per urethral catheter.

158

D6

So maybe they seen him this morning

159

OUT-D4

I didn’t see him==

160

?

( ) he’s getting drained! [laughs]

134

D5

Oh I didn’t know that he was doing that the night before.

135

OUT-D4

Yeah, he was, like, the night before as well, but nothing—I didn’t give him anything last— that night, but this night, um, apparently you guys had written him up for some temazepam?

136

D2

Yeah, yep.==

137

OUT-D4

==It was just for insomnia. He’s been given that at 10, um, but then woke up at about 2 o’clock, started walking around and all this business==so

138

D6

==Yeah apparently he normally walks around, like in his house at night time.

139

OUT-D4

Yeah

140

D6

That’s his normal behaviour

[laughter and unclear chat]



Clinical handover as an interactive event 223 161

D5

==Just not the right place [laughs]==

162

D6

You know how he was leaking through his penis?

163

D5

Yeah

164

OUT-D4

He was getting – he had per urethral output before as well, as in before the catheter got put in, so, he was incontinent with urine.

165

D6

But that’s a new thing apparently and so.

166

D5

That doesn’t make sense.

167

OUT-D4

Why?

168

D5

Because he’s got an SPC. It must have been blocked, or some problem

169

D6

But they flushed it.

170

OUT-D4

No, but he had an actual per urethral output.

171

172

D5

OUT-D4

173

Yeah, yeah, that’s what I mean. He shouldn’t – well shouldn’t be, so OK. So ... urolology hasn’t seen the patient? Well I don’t know, like I said, there was a catheter this morning, so I’m assuming. I didn’t put the catheter in … must have been urology.== [Unclear chat and laughter]

174

D6

==Unless ( ) put it in!==No, OK! [laughter]

175

OUT-D1

==No, I did one for ( ) last night.

176

OUT-D4

and the nurses wouldn’t have done it

176

D6

( ) in his delirium. [laughs]

177

OUT-D4

Um, the other thing that I did … I didn’t see if you guys did anyth—CT brain or anything like that. I don’t know if you guys wanted to consider that, but um

178

D5

That’s ( ). I mean, he’s got fever and stuff, he’s got a clear pulse

179

OUT-D4

==you got a good (??)

180

D6

Umm, was there another patient by the name of Janie McMahon that gave you any problems? In stroke respiratory, Bed 3, ( )==

181

OUT-D4

==Nup.==

182

D5

==Why would she?==

183

D6

She’s getting a bit delirious (??)

184

?

[quiet murmur]

185

D6

She thought Heidi Montag was one of the nurses. She looked at a magazine and said she works here.

186

D5

Oh really?

187

OUT-D4

Maybe she does! I haven’t seen her. [laughter]

188

D5

She’s (growing?) isn’t she? [laughter] [people packing up papers]

189

OUT-D4

[to D5 only] Yeah, I’m assuming it was urology that did that, because==

190

D5

==That’s alright, we’ll have a look and see what’s going on. Martin ( ) delirium patient. [unclear chat and laughter]

191

OUT-D1

Great, that’s all.

192

D5

Thanks Tamu.

5.1. Contrasting features in Extract 2 Table 1 presented earlier summarises the interactional and informational contrasts between OUTD4’s handover and that of OUT-D1. Interactionally, OUT-D4’s presentation is not assertive or confident. In turn 128, OUT-D1 clearly resigns the dominant speaker’s role (That’s [it] from me) and gives OUT-D4 the turn (I think Hal has got one). OUT-D4 does not have to claim the role assertively and his subsequent performance suggests he would not be able to do so. His turns are often short (turns 129, 139, 143, 148, 157, 170, 176, 179,181 and 189 are all only one clause). His longest turns (e.g. 133, 135 and 137) are from three to five clauses long. And when he does have the floor, OUT-D4 makes surprising use of it, asking questions rather than making statements (turns 129, 144, 167 and 179). Unlike OUT-D1, OUT-D4 does not use clear framing words to initiate his handover (he starts with a question to the other participants); nor does he clearly sign off. In fact, his handover almost trails off until D5 takes control in T190 and says we’ll have a look and see what’s going on. Informationally, OUT-D4 does not present the clear information stages used by OUT-D1. He provides no background to his patient and no presenting problem. He assumes considerable shared knowledge. Current treatment information is muddled (T135 last night/this night). Significant events for the patient are almost buried in the handover (T150 clambered out of bed and had a fall) and OUT-D4

224 Suzanne Eggins and Diana Slade does not immediately provide the expected followup statements about the outcome. His recommendation for ongoing care is not clear: e.g. in T177, is OUT-D4 recommending his colleagues do this or not? The information OUT-D4 does provide is vague and tentative: e.g. T137 walking around and all this business; T152, nothing too obvious. OUT-D4 repeatedly signals his lack of knowledge when he might have been expected to have established the facts (T152, T155, T172, T177). OUT-D4’s lack of confidence and unsatisfactory presentation of clinical information has two main consequences. Firstly, it means his handover relies on dialogic elicitation by other interactants. Because OUT-D4 does not give the information the others need, they take over and elicit it. In T138, D6 makes (an unlikely?) suggestion. In T141, T143, T145 and T147, D5 queries the patient’s behaviour and diagnosis. In T149, D5 probes for patient’s status and in T153 and to the end D5 offers possible explanations and elaborations. Secondly, OUT-D4’s poor interactional skills allow the interaction to deteriorate. To explain this key point we need to comment more generally on interactional structure in events like handovers. 5.2. Pragmatic structure and turn-taking management in clinical handovers As research summarised by Heritage and Clayman (2010: 17) shows, institutional interactions typically draw on a more restricted, context-specific and specialised range of interactional practices than casual conversation. These restrictions include a focus on achieving limited and specific pragmatic goals. Handover participants talk to pass on clinical information, accountability and responsibility for patient care. By contrast, casual conversationalists talk to enjoy each other’s company (see Eggins and Slade 1997/2004). Goal-oriented activity types (Levinson 1979), such as many institutional interactions, typically involve participants performing different but complementary communicative roles within the dialogic exchange structure, e.g. one participant initiates by giving information; one responds by acknowledging. Such role differences are reflected in the predictable and tight turn-taking structure exemplified in Extract 1 (OUT-D1 gives information; D2 checks and queries it). In goal-oriented activities, talk that interrupts and distracts from the activity’s purpose are resisted and interactional diversions such as humour, digressions and disagreement – all very common in casual

conversation – are usually kept in check by the participant(s) with the strongest vested interest in achieving the activity’s goal. The first 13 minutes of the handover event display the structural patterns common to goaloriented institutional interactions: OUT-D1 keeps the interaction on track, resisting interruptions. However, in the final six minutes of the event the structural ‘tightness’ and focus of the interaction deteriorates. Diversions from the pragmatic goal are not effectively managed by OUT-D4 who does not appear able to take responsibility as the participant who now has the strongest interest in achieving the pragmatic goal of handing over his information. The humour that begins in Extract 2 around T160 is one expression of the loss of control and focus in the handover. We recognise that shared humour plays an important role in building team cohesion and interpersonal relationships in the workplace (see Eggins and Slade 2004: 155–166). Relevant here is who manages the humour and how much impact they allow it to have on the purpose at hand. When handing over his final patient, OUT-D1 shares a humorous moment with his colleagues. He describes how a registrar told him that an elderly woman with a tremor needed neurological testing when it was clear to OUT-D1 that she had rigour. But OUT-D1 initiates the humour – he laughs first, which gives permission for the others to laugh too. And he maintains control of the interaction – he keeps track of where he is in his information and reasserts his control of the interaction to finish his handover. By contrast, OUT-D4 is so vague in his information that it creates a space for humorous suggestions from his listeners. Because of his poor command of the interaction, this humour is not in his control and interrupts the handover. He has trouble reclaiming the floor and the interaction loses pragmatic momentum. In fact, other participants need to take on assertive roles, e.g. in T190 D5 closes OUT-D4’s handover for him, by offering to sort out what is going on with the patient.

6. Implications The close-up focus on the example above and other authentic handover interactions allows us to suggest communication strategies – both for those giving the handover and for those receiving it – likely to contribute to effective handovers.

6.1. Communicative skills that help a clinician give a strong handover Interactional skills • Be assertive enough to take, hold or regain the floor. • Introduce the patient and ensure you have the attention and acceptance of responsibility from those you are handing over to. • Use framing expressions to signal the start and end of your information. • Give space after core information for recipients to ask questions, confirm, probe. • Clearly and concisely answer any queries immediately. • Check all key points have been understood by your recipients. Informational skills: • Use scaffolding nouns like ‘problem’, ‘plan’, ‘difficulty’ and conjunctions like ‘next’, ‘last’ to help your listeners follow the structure of your information. • Structure each handover systematically to include: identification of patient and their location; presenting problem; observations and hypothesis/diagnosis; actions taken so far; current status of patient; advice and recommendations on care plan to incoming team. • Make all information specific: people, places, times, dosages, tests. • When dealing with co-morbidities, ensure that each condition is dealt with systematically before you discuss the next condition. 6.2. Communicative skills that help a clinician receive a handover Interactional skills: • Listen to the speaker carefully but do not be afraid to cut in when you need to. • Ask checking questions if you want to confirm information you think you have heard. • Ask clarification questions if you need more information than the speaker has given so far. • Ask cumulative questions to check connections between bits of information. • Ask again and again until you get answers you are happy with.

Clinical handover as an interactive event 225 Informational skills: • Before the handover ends, make sure you are clear on the patient’s name and location, presenting problem, what the speaker has done, the hypothesis/diagnosis, and what you need to do to manage the patient. • Summarise the future management plan and actions you need to undertake and ask the outgoing doctor to confirm your summary. We can also suggest communicative behaviours that those handing over would be wise to avoid. 6.3. Communicative behaviours that detract from effective handovers • • • • • • • • • • •

Being unable to hold the floor to deliver key information Lacking fluency and pace Hesitating frequently Failing to structure information to cover all essential components in a logical sequence Assuming background knowledge about a patient Not having found out all the facts you could reasonably be expected to have checked before the handover Being tentative with factual information Being vague and making generalisations Relying on questions from listeners to elicit key information Giving incomplete answers Losing control of the handover through too many diversions.

7. Conclusion Investigations into patient safety are often approac­ hed multi-dimensionally through studies that gather numerical and statistical data on environmental factors, technical and diagnostic errors, fatigue, pharmacological and surgical mistakes (WHO 2007). Researchers typically investigate the causal nature of clinical incidents, rather than the actual contextual happenings of what transpires at a communicative level between clinicians and patients. They also often neglect to explore how communication, alongside what clinicians do medically, may play a part in patients being at risk. Our research suggests that an effective handover involves all participants collaborating to manage both information and interaction in the communicative accomplishment of clinical handover.

226 Suzanne Eggins and Diana Slade These findings suggest that mandating the use of information management protocols like ISBAR may help outgoing clinicians structure their information and therefore provide useful training tools for junior staff. However, clinicians must also be offered skills development in how to manage multi-party interactions to achieve their pragmatic purpose efficiently and effectively if clinical handovers are to achieve the safety and quality benchmarks that management, governments and the public have a right to expect. We are currently exploring the interactive dimensions of handover more fully in a three-year national project studying handovers of medical and mental health patients from emergency departments to wards, between wards and from rural to urban hospitals (ECCHo 2012). The project has already led to training interventions in handover communication skills that have been very well received by clinicians and have produced excellent results in three-month post-intervention evaluations (see Eggins and Slade under review; Eggins and Slade in preparation).

Acknowledgements and limitations Data used in this paper was collected by Doctors Jeannette McGregor and Marian Lee. We thank the participating staff at Canterbury Hospital and acknowledge the support of the NSW Health Department and UTS in funding the research. The research was carried under ethical guidelines approved by the NSW Department of Health and UTS Human Research Ethics Committees. The data was confined to one Australian public hospital only and may not be representative of other hospitals. Although some handovers were video recorded, many were audio recorded only and this may result in misinterpretations by researchers. Qualitative research by its nature cannot claim to be statistically representative.

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Clinical handover as an interactive event 227 Effectiveness of Improvement Interventions in Clinical Handover. The eHealth Services Research Group University of Tasmania for the Australian Commission on Safety and Quality in Healthcare. Retrieved from http:// www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-05 Yates, J. and Orlikowski, W. (1992) Genres of organizational communication: A structurational approach to studying communication and media. The Academy of Management Review 17 (2): 299–326. Ye, K., Taylor, D. M., Knott, J. C., Dent, A. and MacBean, C. E. (2007) Handover in the emergency department: Deficiencies and adverse effects. Emergency Medicine Australasia 19 (5): 433–441. http://dx.doi.org/10.1111/ j.1742-6723.2007.00984.x Suzanne Eggins has a BA (Hons) and PhD in Linguistics from the University of Sydney and postgraduate degrees in journalism, professional communication and applied linguistics. She taught and researched in professional writing, linguistics and children’s literature at the University of New South Wales for 15 years. She has since worked in editing and publishing and is now a health communication Research Fellow with the University of Technology Sydney. Suzanne is the author of An Introduction to Systemic Functional Linguistics (2nd edition, 2004, Continuum, London,) and is co-author of Analysing Casual Conversation (with Diana Slade, 1997, Equinox, UK). Address for correspondence: Faculty of Arts & Social Sciences, University of Technology Sydney, PO  Box 123 Broadway 2007 NSW, Australia. Email: [email protected] Diana Slade is Professor of Applied Linguistics at the University of Technology Sydney. Her main research areas are the description and analysis of spoken English, workplace communication and culture particularly in healthcare settings, TESOL syllabus design and methodology and cross-cultural communication. Her PhD related research was on the analysis of English casual conversation, and her books include Conversation: From Description to Pedagogy (with Scott Thornbury, 2006, Cambridge University Press); Analysing Casual Conversation (with Suzanne Eggins, 1997, Equinox) and Minority Languages and Dominant Culture: Issues of Equity, Education and Assessment, (with Kalantzis and Cope, Falmer Press 1990). Address for correspondence: Faculty of Arts & Social Sciences, University of Technology Sydney, PO Box 123 Broadway 2007 NSW, Australia. Email: [email protected]