3Emergency department medical handovers as teaching and learning opportunities

Jeannette McGregor and Marian Lee

3.1A morning round in the emergency department

The emergency department team gathers around the bed of a male patient in resuscitation room two. This is the sixth patient the team has visited since the morning round began at eight o’clock this morning. It is now eighteen minutes past eight. The team moves quickly from patient to patient, with an eye on the front door of the emergency department and a conscious need to work efficiently. The anticipation of the arrival of new patients needing acute care or the likelihood of a patient suddenly deteriorating means that time is compressed here in the emergency department. The patient in resuscitation room two is conscious and alert. The light is over-bright. Constant, distracting sounds bounce off the hard surfaces of the room. A group of nurses caring for a patient in the next bed speak together in loud, purposeful voices. There is no privacy for either patient. The noise and the lack of privacy present considerable challenges to communication that the team must manage. Many patients arrive at the emergency department as strangers and the context can be a bewildering one for them. Few road signs are available for patients and their carers beyond the obvious institutional signs which help them identify staff in the emergency department: the nurses are distinguishable by their uniforms; the doctors by the stethoscopes they wear around their necks. All staff members wear identification badges that announce their first names and roles in the emergency department. The badges are a concrete indication of the hierarchy and the range of knowledge and experience among team members. They also provide a name for patients and carers to remember.

There are five people attending this emergency department medical handover – the nurse unit manager, the emergency department consultant (the most senior member of the medical staff), the day registrar and two junior medical officers (one has been caring for the patient overnight; the other is just starting her shift). Emergency department medical and nursing team roles are specific, but the people taking these roles change each day, just as most of the patients in emergency departments change each day, often after a number of hours. By comparison, in in-patient wards, medical and nursing team roles are more likely to be filled by the same staff members each day, and as a rule, patients remain in hospital for longer periods of time. The result is that in-patient team members have more time and opportunity to gather and record information about patients and to develop a shared memory about them.

Patients regularly present at emergency departments with acute illness or injury so the margin for error is small and the need for the exchange of accurate clinical information and shared decision-making during handover is high. The clinical acumen of senior emergency department clinical staff is crucial to the safety of many patients, and senior doctors and nurses in particular are alert to the potential for risk here. The clinical information about the male patient in resuscitation room two that is shared and distributed among team members during the round and also recorded in writing will provide a layer of safety in case he deteriorates over the next couple of hours. Patient information is not systematically recorded in electronic form during handovers in this emergency department. However, most team members standing around the patient’s bed clutch paper and pens, which suggests an intention to communicate or to record something during the handover.

Team members gaze briefly at the patient in resuscitation room two before turning their attention to the junior medical officer who is about to begin the handover. Direct access to the patient at the bedside allows the team to engage with the patient and to observe his condition firsthand. However, impressions about the patient’s condition are not shared among team members at this point. Instead, the junior medical officer begins, without preamble, to transfer the information about the patient to the most senior doctor present (the emergency department consultant), who is standing next to him: ‘This is a sixty-five years man, um diabetic and er … ’5 The consultant unexpectedly interrupts the junior medical officer by signaling a discovery: ‘Ha, ha!’ As if uncertain what the consultant intends by this interruption, the junior medical officer proceeds with his information transfer in a slightly disconnected way: ‘ … ischaemic … ischaemic heart … disease.’

By now, the consultant has captured the attention of the group: ‘Look at this! Inserts!’ He and the registrar share an aside from which the nurse manager and the junior medical officers are excluded. Although the relevance of the inserts is not explained, the nurse manager and the junior medical officers appear to expect to be excluded from senior level medical discussions and do not ask any questions.

Once the aside is over, the consultant refocuses on the junior medical officer: ‘Anyway … go on.’ There is no doubt who is in charge of the process. Despite the recent interruption, the junior medical officer picks up where he left off: ‘Diabetes and ischaemic heart disease. He had … angiogram.’ The junior medical officer speaks English as a second language, and this, combined with his soft voice and the ongoing noise in the room, makes it difficult for the consultant and the other team members to follow what he is saying. Again the consultant interrupts: ‘He was … sorry?’ ‘Diabetic’ the junior medical officer replies. The consultant confirms the patient’s diabetic status and scribbles some hasty notes as the junior medical officer is talking. Some other team members do the same. By engaging directly with the junior medical officer, checking and clarifying information as he records it, the consultant demonstrates his overall responsibility for the safe care of the patient. The junior medical officer proceeds with the handover, using a familiar, narrative style of presentation:

Once again the consultant checks his understanding with a brief query about what the patient was doing when the accident occurred: ‘He was?’ The junior medical officer repeats the information and proceeds with the transfer:

The junior medical officer does not make it clear whether the patient developed chest pain in the ambulance or in the emergency department but no-one asks any questions. The narrative continues:

At this point the junior medical officer checks his own notes, and finishes the narrative by indicating where the injury was: ‘… in the neck here.’ Despite the disorganized nature of the information in this part of the narrative, which jumps between the administration of medication by an ambulance officer, the patient’s pain level, the results of the ECG and the blood tests, back to the time of the accident, a provisional diagnosis and so on, there are still no questions or clarifications from the team. The consultant asks the junior medical officer for his assessment of the situation: ‘So … so he’s likely to go home?’ The junior medical officer replies in the affirmative and the consultant agrees with him: ‘I’d anticipate that.’ This shows positive support for the junior medical officer’s decision. Although the care plan appears settled between consultant and junior medical officer, the nurse manager suggests an additional step: ‘Should we x-ray his neck … considering the mechanism … just to make sure?’ The consultant agrees and acts upon her suggestion by firstly checking with the junior medical officer about the patient’s level of pain: ‘Is he tender at all?’ Then he and the junior medical officer discuss it with the registrar. The nurse manager takes an alternative course and checks directly with the patient: ‘You’ve got pain, haven’t you?’ The patient nods. Pain is taken very seriously in the emergency department and the consultant decides to examine the patient himself (using the collective pronoun ‘we’ to emphasize the team role): ‘We’ll have a look at him.’ What we see here is a number of different perspectives on the clinical situation, including the patient’s own. However, it is significant that despite the fact that the team members are standing at the patient’s bedside, only the nurse manager addresses the patient directly.

The focus now turns to the patient and to the consultant, who asks the patient: ‘How are you feeling?’ This is the first time that the consultant has spoken directly with the patient. With the patient’s full co-operation and engagement, the consultant then makes a detailed examination of the patient’s neck, shoulders and back. While he is examining the patient, the consultant takes the opportunity to fill some gaps in the junior medical officer’s original narrative. He asks the patient: ‘Who did your stent?’ He finds out both the surgeon’s name and the location of the hospital where the stent was inserted and records it in his notes. This aside hints at the consultant’s broader responsibilities, which require him to have a clear overview of all patients in the emergency department. It also demonstrates a communication strategy that emergency department doctors practise by necessity – they find out as much information as they can when the opportunity arises, before they are diverted elsewhere and have no time to return to particular patients to follow up on any gaps in the information transfer. The junior medical officer then indulges in some humorous banter with a group of emergency department staff who are pushing a patient on a trolley past resuscitation room two. The junior medical officer says: ‘Reversing in the hospital shouldn’t … shouldn’t do 40 kilometers an hour!’ and everybody laughs, creating a sense of solidarity among the emergency department staff and lifting the mood for a moment.

As the team moves out of the patient’s earshot, the nurse manager makes an additional suggestion: ‘Because it could be a worker’s comp thing. So we need to do a blood alcohol.’ The consultant acquiesces: ‘Put it this way, I think there’s no harm in doing a blood alcohol.’ Prompted by the nurse manager’s suggestion, he then emphasizes the broader professional responsibilities of clinical staff to comply with the law. This requires that they establish the blood alcohol level of any driver, cyclist, horse rider or boat skipper involved in an accident, with possible legal consequences if they do not. This is a useful lesson for the junior medical officers, who may not have thought beyond their clinical responsibilities in the emergency department. Only five and a half minutes have passed since the team first arrived at this patient’s bedside. They now move quickly to the bed of the next patient to begin the next transfer of information.

3.2Factors at play during emergency department medical handovers

The description of the scene above is but one example of a ubiquitous and routine work activity that occurs three times a day, in every emergency department, in all public hospitals in Australia. It is called an emergency department medical handover and it occurs when an outgoing doctor transfers patient information and primary responsibility for patient care to the incoming team. Although patients can present at emergency departments with a wide range of symptoms and injuries and thus very different needs (Lawrence et al. 2008), our observations showed that emergency department medical handovers follow a broadly similar sequence of activities to those described above. By unpacking the major factors that are at play in the events described above we can better appreciate the complexity that is involved in the handover process.

First we see the impact of the emergency department context on the communication between the care team members. The emergency department is noisy and distracting, with high levels of ambient noise. We note that the emergency department medical handover is triggered by a change of shift, which highlights the organizational priorities of the hospital institution. Next we see that a number of people are involved in the communication: four doctors, a senior nurse and the patient. All of the healthcare professionals bring with them different grades of experience and expertise and we observe some different approaches to handover and some indications of different disciplinary concerns.

For example, the junior medical officer focuses on transferring patient information to the team and briefly describes what he did for the patient over the last shift. We note too that the senior doctor (in this case the emergency department consultant) takes a leadership role during the handover, manages the information transfer, accepts suggestions from team members and takes a few moments to emphasize the professional responsibilities of medical staff beyond their clinical duties. The nurse manager draws on her experience and expertise in the emergency department context to influence key actions following the information transfer. However, we also see that the exchange of information about the patient is limited for the most part to a dialogue between the junior medical officer and the consultant.

In addition, we observe the way the team members do certain things to gather information about patients – such as the way they stand around the patient’s bed and position themselves in relation to the patient and to the other team members. We see that team members have the opportunity to observe the patient firsthand during bedside handovers although the understandings they gain by doing this are not shared with other team members. Background noise is created by machines operating nearby and team members consult and write notes – but again the understandings gained from these are not shared.

Finally, we note what people actually say – the words that are exchanged. Some of the junior medical officer’s words are inaudible because of the noise and because he speaks with little awareness of his listeners’ communication needs. At times the information is disorganized because it is presented in an unstructured way and jumps from one subject to another in an apparently random fashion and listeners have to try to make sense of it. Added to this, the junior medical officer speaks English as a second language, which is a further challenge for his listeners and for himself. The words are a transfer of patient information, which describe the patient’s symptoms, his medical background, the results of assessments carried out since his arrival at the emergency department and his current condition, but the information is difficult for all team members to follow at times because of the constant noise. Only the consultant checks and confirms information. Only the nurse manager suggests additional actions. Crucially, our scene highlights a number of communication problems that we observed during emergency department handovers at our site. These include the transfer of disorganized information, the lack of time and space, constant service demands, high level background noise, interruptions, lack of privacy for patients and team discussions, different grades of knowledge and experience among team members and second language issues.

3.3Clinical handover during ward rounds in the emergency department – a view from the literature

This crucial, complex communication process of information transfer known as clinical handover is closely related to patient safety and the quality of ongoing care (Ye et al. 2007) yet it remains a subject of concern among clinical professionals the world over (Cheung et al. 2010; Gibson 2010; Wong et al. 2008; Beach et al. 2003). Clinical handover is acknowledged as one of the most frequently performed tasks in medical care (Bomba & Prakash 2005). It is described as the communication of information to support the transfer of patient care between individual and teams of healthcare professionals and to maintain professional responsibility and accountability (Mistry et al. 2010). The literature emphasizes the accurate transfer of patient information during clinical handover (for example, Nagpal 2010; Patterson et al. 2004; Jorm & Iedema 2008; Bomba & Prakash 2005). Despite this, the point is made that achieving ‘high-quality’ (Pezzolesi et al. 2010: 396) handovers requires an understanding that clinical handover involves more than the simple transfer of information (Pezzolesi et al. 2010; Manser 2011). Our research supports the view that clinical handover in fact has multiple functions (Manser 2011; McFetridge et al. 2007; Patterson et al. 2004). Two important functions involve engaging in a shared decision-making process about patients and their care (Apker et al. 2010; Wohlauer et al. 2010) and achieving patientcentered care (Anderson & Mangino 2006). Other functions include taking the opportunity to review previous diagnoses and treatment plan decisions to accommodate the dynamic nature of illness, and the identification of clinically unstable and deteriorating patients (Patterson et al. 2004). Yet others involve creating opportunities for team building, social interaction, role modeling and training for less experienced staff and for the emotional support of staff and families (Manias et al. 2008; Patterson et al. 2004; McFetridge et al. 2007; Solet et al. 2005).

There is increasing consensus that effective clinical handover is a critical part of ensuring the safe care of patients and patient care continuity (Smeulers et al. 2012; Manser 2011; Apker et al. 2007; Bomba & Prakash 2005) and many studies highlight the deficiencies of clinical handover (Matic et al. 2010; Cheung et al. 2010; Ye et al. 2007). This transfer of patient information occurs at transition points across settings, services or levels of care (Jorm et al. 2008), or when scheduled shift changes occur. It often involves the transfer of patient information between health professionals of different levels of experience and expertise (Bomba & Prakash 2005). In sum, clinical handover emerges as a crucial and complex clinical practice with multiple functions, all tied to the effective and safe management of patients by multidisciplinary teams.

3.4The theory of practice – another way to see the practice of clinical handover

Considerable time and effort has gone into research looking at various solutions (Iedema et al. 2009; Patterson 2008; Patterson et al. 2004; McMurray et al. 2010; Matic et al. 2010) to the wide range of problems identified in the clinical handover process (Raduma-Thomàs et al. 2011; Riesenberg et al. 2010; Coiera et al. 2002). For our research, we chose to apply the conceptual framework of practice theory to emergency department ward round clinical handover practice. This was fundamental to our investigations because it allowed us to investigate the practice of emergency department medical handover in all its dimensions.

So what do we mean by professional practice? ‘Professional practice’ (Green 2009) involves what people do, what they say to one another and the networks of relationships they form with one another at work (Kemmis 2009) and combines what Kemmis refers to as ‘sayings, doings and relatings’ (Kemmis 2009: 25). Practice also refers to the routine activities that people do in their particular field of work and involves a shared and recurrent way of doing things (Gherardi 2008, 2009). For example, the practice of clinical handover is one of the many routine work practices that are embedded in the professional practice of medicine. Other embedded practices connected to clinical handover include taking a medical history from patients, doing a clinical examination of the patient, taking blood, organizing pathology tests and scans and reading the results, writing clinical handover notes, speaking to patients about their symptoms and discussing the patient with colleagues. By observing clinical handover practice as a situated, routine practice, with a repertoire of doings and sayings, we begin to understand how clinicians make sense of what they do and how they perceive their responsibilities, their roles and professional identities during clinical handover – how they relate to one another, what they should do and say, and to whom.

However, to understand particular actions and interactions like those described in the clinical handover scene above, we firstly need to understand how these actions and interactions are shaped by their organizational and physical contexts (Green 2009). We also need to understand how people learn work-based practice and how innovation and change are achieved in the workplace. One argument is that junior doctors learn practice mainly through applying pre-learned knowledge and skills (Manidis & Scheeres 2013; Garling 2008). By contrast, Gherardi (2007: 97) claims that we begin to learn practice by watching, looking, seeing and listening to others as they carry out meaningful work. This view of the learning process is supported by Kemmis (2009: 33) who explains that newcomers watch and learn from the margins until they are gradually absorbed into an organization as they learn to talk, work and relate to others as experienced practitioners. We understand from these two explanations that learning is not simply a cognitive process – it is a relational and embodied one that has practical, physical and emotional aspects as well (Zukas & Kilminster 2012). We learn what is described as ‘knowing in practice’ (Gherardi 2009) by doing work with others (Svabo 2010).

We see learning happening in the emergency department when clinicians communicate with each other (in spoken or written form) or use artifacts (such as scans, test results or patient notes) to gather information, in order to co-construct and distribute knowledge about the patient (Manidis & Scheeres 2012). Lave & Wenger (1991) add another layer when they talk about novices learning through engagement and participation in what they call ‘legitimate peripheral practice’, which takes place under the guidance of more experienced practitioners. This kind of participation is mandatory for junior doctors in the emergency department, where the learning process is strongly tied to the experience and expertise of more senior doctors and nurses (Manidis & Scheeres 2012). Learning also happens when clinicians apply their senses (Strati 2007) to clinical practice, using their sight, touch, hearing and smell. Crucially, we understand that knowledge is not an object that we possess and pass on to others; learning (and teaching) work-based knowledge is a process (Svabo 2010) that is situated in a particular place, at a particular time. Thus, we learn an array of normative behaviors (Gherardi 2008) as part of becoming a professional. One might expect that professionals who see particular established practices as part of their professional identities might resist changes to practice. However, Gherardi (2012) explains that change and innovation occur on a daily basis through the routine work practices of people who are doing their jobs. This continuous process emerges through the ongoing refinement and negotiation of practice by practitioners themselves. It is our firm view that clinical handover practice would be significantly improved if health practitioners placed more emphasis on the value of doing work together, in all its aspects, and if all members of emergency department medical teams were encouraged to participate and engage in the handover process together. We will explore this thesis in the following sections of this chapter.

3.5Our research site, aims and methods

The research site for our clinical handover study was the emergency department of hospital A, a metropolitan public hospital in Australia. The broad aims of the study were three-fold. Firstly, we focused on understanding the many complex activities and actions or the ‘sayings, doings, relatings’ (Kemmis 2009) that contribute to communication during emergency department medical handovers. Secondly, we sought to explain the many challenges to communication that are created by these activities and the conditions in which they occur. Thirdly, we focused on identifying the teaching and learning opportunities that are available to all clinical staff, including junior medical officers, during emergency department ward round handovers. To understand how healthcare professionals and their patients manage the complex, dynamic and demanding communication process of emergency department medical handover, and how they organize the considerable amount of information involved, we used a qualitative approach (Iedema 2007). We combined two complementary modes of analysis: a qualitative ethnographic analysis of the clinical handover practices of emergency department staff and a language analysis of the actual spoken handover interactions between doctors and nurses during the transfer of patient information and responsibility for care.

Our qualitative ethnographic analysis of the practice of ward round handover was in two parts: firstly, detailed observations of the situational context and the normative behaviors of the clinicians themselves; secondly, semi-structured interviews with clinicians from our hospital site. Our observations were framed by the activities that occurred around morning ward rounds, when doctors going off the overnight shift (a registrar and a junior medical officer) gave handovers to staff commencing the day shift. These emergency department medical handovers involved the transfer of patient information and the ongoing responsibility for the care of all patients who had been in the emergency department overnight. Within this frame, our specific task was to observe the physical and organizational environment of the emergency department and to understand the impact of the emergency department context on the practice of ward round clinical handover. At the same time, we sought to identify any factors in the practice of handover that had a negative impact on the effectiveness of handover communication and the learning of handover practice by junior doctors. We also noted the many interrelated aspects of clinical practice – both spoken and unspoken – that were on display for clinical staff to observe and learn from, including facial expressions, gestures and tone of voice.

To test our observations against the professional views of clinicians from the hospital site we conducted 15 semi-structured interviews with doctors and nurses at different levels of seniority, with allied health professionals and with relevant administrative staff. A particular interest for us in the interviews was to establish a consensus around any teaching and learning that occurred during clinical handover practice.

As part of our investigations, we analyzed 30 transcripts taken from the audiorecordings of ward round handovers. These provided us with detailed insights into the way information was exchanged between junior and senior doctors and nursing staff. In the next chapter we describe the learning tool we developed from our analysis of these transcripts. Thus, we combined four complementary datasets: the audio recordings of actual clinical handovers; the transcripts of these handovers; our observations of what clinicians did and said during the transfer of patient information; and the transcripts of our interviews with clinicians. In combination, these datasets provided us with a powerful representation of ward round handover practice. Ethics approval for the study was given by the local health department and by the Human Research Ethics Committee at our university. Informed consent was obtained from all participating staff prior to recording.

3.6Challenges to effective handover in public hospital emergency departments

One of the initial tasks of our research was to identify and explain the many challenges to communication and learning that were created by the physical and organizational context in which the emergency department medical handovers occurred. What we observed and recorded represented a formidable challenge. As reflected in this chapter’s opening scene, we found the emergency department to be a complex, eventdriven, time-pressured and critical workplace environment (Eisenberg et al. 2005; Cheung 2010), in which practitioners frequently need to make life-saving decisions.

Our first observation was that emergency department practitioners constantly manage significantly high levels of ambient noise from monitors, patients in pain or distress, constant background talk from other care teams working in close proximity, or the sounds of staff maneuvering cumbersome beds, trolleys and equipment into position. Clinicians also manage multiple disruptions including pagers, phone calls, or requests for information or assistance. Emergency department teams work quickly in this time-pressured environment and are always alert to the high level of service demands on the emergency department, which is open for 24 hours every day, with limited resources of time, space, beds and medical staff. The direct impact of these contextual factors on communication and decision-making processes means that emergency department doctors face cognitive challenges not often confronted by doctors in other contexts (Sklar & Crandall 2010; Coiera 2002). The result is a formidable challenge to communication.

Next we familiarized ourselves with the organizational priorities of the emergency department, which are built around the management of staff and patients. Regular shift changes for staff are a key part of the organization. For example, medical ward rounds are scheduled three times a day in hospital A’s emergency department, as in most other Australian emergency departments. The primary purpose of the round is to determine the current status and plan for each patient in the emergency department. It includes a handover function for doctors who are concluding their shifts (Cunningham 2009). Typically, during each round clinical handovers are given for 12 to 14 patients in beds and two to six ambulant patients with minor injuries in a section of the emergency department referred to as ‘fast track’. Emergency department medical handovers in our data ranged from 20 seconds to 5.13 minutes per patient, with an average duration of 2.28 minutes per patient. For those patients who had just arrived in the emergency department there was little information to transfer to the team during the round beyond their level of stability and the immediate treatment plan. We found that the round included both junior and senior doctors, so there were always different grades of experience and knowledge among care team members.

Senior nursing and allied health professionals also accompanied the round and nurses working at the bedside when the round was happening contributed information to the handover when they thought it was relevant or if doctors sought their expertise. Consequently, experienced health professionals were always present as mentors and models of practice for junior medical officers in training. However, our data showed that during 73 percent of handovers doctors alone contributed information. Concurrent activities did not cease during the round. We observed that doctors and nurses at our site were required to work under constant pressure to meet specific workplace targets that appeared to be time and resource focused. There were always new patients waiting at the front door for admission to emergency departments despite the fact that beds, space and staff numbers were limited. Casual staff added further challenges to communication between emergency department staff members.

We also observed interpersonal factors that impacted directly on communication, such as variations in communication skill levels among care team members and the role of hierarchy and personality, all of which were on display during ward rounds at different times. Patient factors also played a part, such as variations in acuity, the dynamic nature of disease – which can change hour to hour – difficulties accessing a patient’s background information, uncertain diagnosis, poor control of English by patients and their families and the impact of pain. Table 3.1 below summarizes the multiple factors that we assessed as having a negative impact on emergency department communication in general and on emergency department medical handover in particular.

Tab. 3.1: Factors that impact on the effectiveness of communication in the emergency department

3.7Emergency department medical handover practice – doings, sayings and relatings

Another key part of our clinical handover research was to observe and record the range of complex activities and actions that combined to form emergency department medical handover practice and to identify the challenges to communication and learning that were created by them. We understand that emergency departments are organizations that rely on routines, systems and repeated applications of clinical knowledge (Manidis & Scheeres 2012). Our interest was to observe what emergency department team members routinely did and said when they communicated patient information to one another during emergency department medical handover. This required us to observe the recurrent activities and actions (Green 2009) of individual team members at the bedside. We focused in particular on the way team members related to one another during handover. We found that communication processes dominated the activities and actions of clinicians (Coiera 2002). Team members built up information about patients by communicating directly with one another and by participating in care activities together although not all team members were routinely included in these activities. Practitioners also observed the patient firsthand and checked artifacts like monitors, scans, notes and test results. As mentioned earlier, we found that individual patient handovers broadly followed a similar sequence of activities to those described in our opening scene.

The emergency department medical handover that occurs during the 8 am morning round constitutes the initial handover for patients who arrive at the emergency department during the night or first thing in the morning. Many of these patients arrive without a medical history or a diagnosis. This initial handover thus provides the basis of information that doctors use when making a diagnosis and planning subsequent clinical care. It is also the information that is transferred to other doctors during successive handovers, including those in other hospital wards. Patients do not stay in emergency departments for longer than 24 hours as a rule, and often their stay is much shorter, so there is little time to build up new information or to confirm inaccurate or missing information (such as allergies or medications). Once patients are stabilized, initial diagnosis is established in as timely a manner as possible, a treatment plan or discharge plan is put in place, patients are either admitted to a hospital ward for further care and treatment or are discharged home. However, the dynamic nature of disease means that it evolves and rapid clinical changes may be evident in the first few hours that a patient is in the emergency department. As a result, patient stability may also be dynamic. In acute cases, treatment frequently begins in emergency departments before investigation results are available and a definitive diagnosis can be reached. New patient information emerges as diseases evolve and practitioners change treatments in response.

This initial handover has implications for patient safety that cannot be overstated: despite the many contextual challenges in emergency departments, team members must endeavor to transfer accurate, relevant and up-to-date information, distribute it across the team, to other emergency department staff and then to clinical staff who do not work in the emergency department (such as staff in other wards, specialists or GPs), either in spoken or written form.

Our observations showed that what team members did and said, and the colleagues with whom they talked during emergency department medical handovers, depended on their level of responsibility and their likely engagement with particular patients over the following shift. We found two different patterns of engagement. The consultant had overall responsibility for every patient in the ward, and for this purpose took an overview of proceedings. From this view, the consultant took a leadership role and asked questions and clarifications directed more towards global patient management issues. However, the consultant also zoomed in on the specific clinical details of individual patients. Consultants led 67 percent of our recorded handovers. Other doctors responsible for the ongoing care of individual patients (including registrars and some junior medical officers) asked more direct questions about the patient’s symptoms, proposed treatment plans and anticipated complications, which they checked and clarified with the doctor giving the handover. This two-tiered approach to patient management provided an obvious mechanism for patient safety: different doctors were responsible for the macro and micro aspects of care.

From our data we identified a range of potentially problematic patterns in junior medical officer communication behavior. First, we noted that the junior medical officers generally played a minimal role in handovers given by their more senior colleagues. Often they contributed nothing at all. More significantly, junior medical officers rarely asked questions or clarifications or offered any comments during clinical discussions between senior doctors at the bedside. During the 30 transfers of patient information that we analyzed, 146 questions were asked overall. Of these 146 questions, senior doctors (consultants and registrars) asked 137, the nurse manager asked seven and junior medical officers asked only two.

Second, when junior medical officers had the responsibility for giving a clinical handover for their patients (87 percent of the total handovers recorded in our data), they sometimes appeared confused when senior doctors asked them questions or checked information, in line with their responsibilities as senior practitioners. Often senior doctors asked questions in a rapid, shorthand style (‘Bloods?’), without expanding on the clinical reasons behind their questions (e.g. ‘So to rule out an infarct, have you done the bloods?’). Valuable time was sometimes spent dealing with the junior medical officers’ confusion about what response was required. The contested space of the emergency department was no doubt a significant factor contributing to these two communication patterns that precluded and confused junior medical officers. We found that the many contextual pressures in the emergency department had a negative impact on spoken communication generally, and on teaching and learning opportunities in particular. For example, there were numerous occasions when, in a more sympathetic context, senior doctors could have taken extra time to explore relevant clinical issues with team members and make more transparent links between clinical issues, but the time and service pressures of the emergency department made this difficult. For the less experienced team members, it was a lost opportunity.

Third, although junior medical officers tended to structure their minimum datasets using a systematic framework (such as iSBAR), the information they provided to the team was often disorganized and lacking in cohesion. For example, junior medical officers may have included all relevant categories of information in the handover (e.g. the patient’s identification and stability level, presenting problems, medical history, examination, investigations and management plan) but did not present them in a sequence that logically mirrored the clinical care process and allowed listeners to follow the sequence of events that had occurred since the patient’s arrival at the emergency department. Junior medical officers did not always clearly identify topic changes during the handover, such as a change from the patient’s medical history (‘He came in on a background of … ’) to information about the investigations they had ordered (‘So then I ordered a CT scan … ’), which would make the information easier for listeners to follow. Nor did they use words that would help listeners to make connections between the stages of the handover (such as ‘So then we … ’; ‘The next thing I did was … ’).

Fourth, some junior medical officers showed little awareness of their listeners’ needs during the transfer of information. Often it was difficult to hear the information clearly because junior medical officers spoke in soft voices without looking directly at their listeners or directing their talk to the senior doctor only. Junior medical officers often buried important information, such as an unclear diagnosis or pending test results (which were mentioned in 53 percent of our recorded handovers) under less relevant details. Unfortunately, senior doctors did not provide explicit feedback on junior medical officer handover communication in general.

Finally, while it is true that many emergency department patients are seriously unwell, it is significant that in 80 percent of our recorded handovers (of all emergency department doctors) there were no contributions from patients. Table 3.2 below summarizes our key findings of participant contributions during the 30 handovers we recorded.

Tab. 3.2: Participant contributions across 30 recorded clinical handovers

As well as the spoken aspects of the handover, we also observed the physical behaviors captured briefly in our opening scene, such as the way team members gathered around patients’ bedside during emergency department medical handovers. The available space between the beds in the emergency department was scarcely adequate for group communication, so the doctor who was giving the handover routinely stood closest to the senior doctor who was leading the round. The doctor taking over the care on the next shift stood next to them. The nurse manager then stood as close as possible to these three. The remaining team members (a doctor and different allied health staff, depending on the case) gathered where they could, sometimes one behind the other, so conditions for group engagement were not ideal. Team members managed the noisy and chaotic environment of the emergency department by directing their talk to the people closest to them and by speaking briefly and at speed. Inevitably, words were lost to some. In line with their responsibilities, senior doctors took phone calls, responded to requests or attended to other urgent matters during the transfer of information, and then returned to the handover. These additional activities added to the communication burden of senior doctors. Research shows that multi-tasking can affect memory (Coiera 2002) but in the emergency department multi-tasking is a necessary response to the competing priorities of the organization. Concurrent activities at the bedside were unavoidable and created another level of distraction. Disruptions, such as phone calls or requests for assistance from practitioners caring for other patients, were a frequent aspect of emergency department work and were generally ignored by clinicians, although disruptions challenge the way we process information and can also interfere with memory (Parker & Coiera 2000). Finally, as we highlighted in the opening scene, we noted that when doctors made use of artifacts such as monitors, scans, test results, patient notes, or used their senses to build up knowledge for themselves about different patients at the bedside, they did not share this information with other team members.

3.8Clinician perspectives on handover practice

Our interviews with hospital staff covered a wide range of topics. We explored the role of communication during handover, the kind of patient information that should be transferred during handover and our interviewees’ professional experiences of the problems and challenges to handover in the busy context of the emergency department. Every interviewee held a slightly different perspective on handover practice, depending on their ward context, level of seniority, previous experience, roles and responsibilities and profession. This is significant because hospital teams in this jurisdiction are multidisciplinary and many different people, including nurses, doctors and allied health professionals, care for patients both in hospitals and in the community. Information transferred during any handover may well be a crucial part of the patient’s ongoing care at a later date or in another situation. Among our interviewees perspectives differed broadly along clinician groupings:

Interview participants discussed the impact on handover practice of factors such as the experience gradient of doctors and nurses, time pressure, crowded space, high patient numbers and challenging levels of ambient noise, all of which were seen to present negative challenges to communication during handover. Interviewees also offered solutions. These were overwhelmingly focused on emphasizing more standardized approaches to information transfer.

The medical profession’s interpretation of hierarchy was singled out as a particular problem by a consultant charged with overall responsibility for patient safety. He explained that medical hierarchy is interpreted not as a hierarchy of responsibility but as a hierarchy of power. In his view the result is that ‘juniors in the culture of medicine are deferent[ial] to seniors.’ He suggested that this deference means junior medical officers respond to the responsibility of providing information to their seniors in the following way: ‘I won’t tell you that I think the chest pain could be an infarct, I’ll tell you that it’s crushing and radiating down the left arm and I’m using telepathy in the hope that if I use this term or that term you’ll know what I mean – but I’ll never actually say what it is that I’m trying to tell you … Who am I to tell you what I think it is?’ This consultant finished by saying that this traditional deference is a barrier to good communication because it means that communication in the medical professions occurs on a vertical axis with ‘unspoken rules around what you can say and how you say it.’

We found consensus on the teaching and learning role of clinical handover practice among doctors and nurses who were directly involved in giving and receiving handovers in the emergency department. One senior doctor in the emergency department emphasized that junior medical officers had to be encouraged to think beyond the limits of their roles and to focus more broadly on ways to solve patients’ problems because they ‘don’t think beyond their intern and resident duties.’ One of his solutions was to use what he described as a ‘scenario-based teaching’ approach. Essentially, this meant guiding junior medical officers through the issues for each patient, helping them to make connections between each step by engaging them directly in the information transfer. For example, he would ask junior medical officers ‘what sort of problem did the patient present with and as a consequence of that or associated with that … what past medical history they had that is relevant to their presentation’; and ‘what investigations they would have done in order to support the diagnosis which they were going to tell me.’ After he had gathered all the relevant information, this senior doctor would then reflect on it to identify the key issues. If necessary he would ask for clarifications, and would then formulate a plan in conjunction with the rest of the team.

Another senior doctor, who also stressed the importance of senior-led conversations through a structured format, emphasized the teaching benefit of providing a summary at the end of each handover: ‘letting them know at the end: these things have been confirmed, these things have been excluded, these things are normal, these things are outstanding.’ The role of senior doctors as models and mentors for clinical practice was well-recognized by our interviewees, although it was not always seen as a positive. One senior doctor commented ‘so much of junior medical behavior is modeled on their seniors … they pick out the best and the worst habits by senior clinicians.’

3.9Discussion

Researchers and health professionals continue to identify communication as a major driver of the handover process and a major reason for its failures. During clinical handover, information is lost, inaccurate information is transferred, not everyone who needs to know is informed, different care priorities are not considered and patients and families are not included. Context and organizational challenges are investigated and understood. Solutions are proffered: standardize the process; introduce more complex and rigorous checking mechanisms; develop a better electronic patient record system. But despite some significant improvements, the failures continue. The reasons for these failures are identified anew, and the search for solutions continues. As stated earlier in this chapter, we postulate that ongoing care and patient safety following handover will significantly improve if practitioners are encouraged to see the value of participating and engaging in the handover process together, in all its aspects, as part of a team in a community of practice. This is an added guarantee that emergent information about the patient and the treatment process will be added to the handover, errors and misunderstandings will be identified at their source, missing information will be accounted for, information will be shared and distributed among emergency department team members and that practitioners will exploit the many favorable opportunities that arise in every ward round to teach and to learn the practice as part of their everyday work.

Emergency department medical handover is not simply a transfer of information. Our research supports the consensus view expressed in the literature (Manser 2011; Patterson & Wears 2010; Apker et al. 2010; Cheung et al. 2010) and in our interviews with hospital staff, that emergency department medical handover has multiple functions. These functions are built around the need for teams of healthcare professionals to engage in a process of shared decision-making, aimed at achieving safe and quality ongoing patient care. Some handover functions, such as the transfer of patient information, the identification of unstable patients and the review of diagnoses, are focused more on the informational aspects of patient care. To ensure that clear messages are transferred between team members, speakers need to paint a picture that listeners can understand, act upon and then pass on to others when required (Gibson et al. 2010). Other functions, such as social interaction, team building, training and modeling for less experienced staff, are focused more on the interpersonal aspects of workplace communication. Based on our data, we argue that cohesive workplace teams that engage and participate in the process of information exchange together are more likely to co-construct and share patient information than teams in which some members are consistently excluded from crucial aspects of the healthcare narrative.

Despite the challenges to communication that we observed and recorded in the emergency department context during our study, we simultaneously identified many positive opportunities for teaching and learning emergency department medical handover practice in what is often a noisy, chaotic and contested workplace. While clinical handovers are a common feature of all hospitals in Australia, emergency departments are unique in hospital organizations and, paradoxically, this uniqueness creates teaching and learning opportunities for clinical staff that are not available in other hospital wards. Factors that give emergency departments this unique potential for learning include the compressed time frame within which doctors must make clinical decisions about care; the simultaneous management of patients with varied acuity levels; the frequent need for invasive emergency procedures (Lawrence et al. 2008); and the presentation of undifferentiated patients, with clinicians having poor access to background information. Handovers in the emergency department present an ideal forum where knowledge, its application and related clinical skills can be experienced simultaneously and within a rapid time frame. For junior medical officers in particular, emergency departments offer an exceptional opportunity to practice clinical handover skills. We present a simple calculation to illustrate the magnitude of learning opportunities available to junior medical officers in hospitals in this jurisdiction. If junior medical officers spend their scheduled eleven-week term in the emergency department and take part in two ward rounds every ten-hour shift, each round covering an average of 15 patients, the junior medical officers can participate in up to 1,320 emergency department medical handovers. In other words junior medical officers have 1,320 opportunities to learn about emergency department medical handover practice each emergency department term. We propose that maximizing the teaching and learning opportunities for all clinical staff is a positive way to strengthen and support clinical handover practice.

3.10Conclusion

As leaders of emergency department medical handovers, and as practitioners with considerable experience and expertise, senior doctors can play a primary role in maximizing the learning opportunities for less experienced staff by being mindful of the important role played by the informational and interpersonal aspects of communication. At the same time, less experienced doctors and members of other disciplines can improve their learning opportunities by taking a more pro-active role and looking beyond their intern and resident duties. Table 3.3 below summarizes the teaching and learning opportunities that we identified as available to all members of emergency department medical handover teams. The table also identifies mentor and learner strategies that can be used to enhance teaching and learning at each opportunity. In the following chapter we use our new appreciation of the complexity of clinical handover practice to describe some key principles of clinical handover practice and expand on the learner strategies to develop a communication training model which will maximize opportunities for doctors to improve their own handover practice.

Tab. 3.3: Teaching and learning opportunities during emergency department medical handovers