4Strengthening medical handover communication in emergency departments

Jeannette McGregor and Marian Lee

4.1Introduction

In this chapter we describe our development of a training module that doctors can use to strengthen their clinical handover practice. The module arises directly from our qualitative study into the complex practice of medical handover in the emergency department of hospital A, a metropolitan hospital in Australia, described in the previous chapter. We designed the module specifically for doctors who work in the emergency departments of Australian hospitals. In our module we specifically targeted junior medical officers and those involved in their training in hospital emergency departments in the jurisdiction studied. As part of their training, junior medical officers – who are in post-graduate years one and two – spend an average of 11 weeks in the emergency department. If they take part in ward rounds every ten-hour shift, each round covering an average of 15 patients, junior medical officers can participate in up to 1,320 medical handovers during their stay in the emergency department. In other words, junior medical officers have 1,320 opportunities to learn about medical handover practice each emergency department term. However, we believe that both junior and more senior doctors working in other hospital contexts will find parts of the module useful and relevant to their own practice.

We first present the research background to the module, emphasizing the impact of the unique emergency department context on communication generally and highlighting some of the specific communication challenges to clinical handover that our research shows doctors experience in emergency departments. We then describe five key principles of clinical handover practice that have a direct impact on the kind of communication required during clinical handover and we relate these to five key principles of clinical handover communication. In the final section of the chapter we present the communication strategies that constitute the core of our training module and which arose directly from the principles set out in the first sections of the chapter.

The clinical handover practice we observed in one metropolitan hospital in Australia reflects the reality of clinical handover practice in similar clinical environments across Australia and beyond. We encourage doctors to select those strategies that they think will be beneficial additions to their own clinical handover practice and then to incorporate them into their habitual ways of transferring patient information. Doctors can also transfer those parts of the module that they find useful and relevant to clinical handover practice in other Australian hospital emergency departments, in intensive care units or in-patient hospital wards.

4.2The unique features of the emergency department hospital environment

Our research led us to identify six factors that make emergency departments unique healthcare contexts.

4.2.1The high demand for emergency department services

Over 6.5 million emergency department presentations were reported by public hospital emergency departments in Australian hospitals during the period 2011–12 (Australian Institute of Health and Welfare 2012a). We calculate that this means between one in four people in Australia presented at an emergency department in 2011–2012. There are always new patients waiting at the front doors of emergency departments, which remain open 24 hours a day, despite limits on emergency departments, resources and staff. As a result, doctors and nurses in emergency departments are under constant pressure to meet specific workplace targets that appear to be time and resource focused.

4.2.2The wide range of patients who visit emergency departments in Australian hospitals

Doctors and nurses in emergency departments care for patients who present with a wide range of clinical problems, across a number of categories. Patients are triaged according to their presenting problems as soon as possible after their arrival at the emergency department. In Tab. 4.1, we provide a brief description of the five triage categories as defined in the National Triage Scale (Australian Institute of Health and Welfare 2012b), and show the distribution of the total number of emergency department presentations in Australia in 2011–12 across these five categories.

Tab. 4.1: Patient presentations by triage category in Australian public hospital emergency departments 2011–12

Triage category	Description	Number and percent of presentations
5. Resuscitation	Immediate (within seconds)	42,630 (0.65%)
4. Emergency	Within 10 minutes	647,756 (9.9%)
3. Urgent	Within 30 minutes	2,198,840 (33.6%)
2. Semi-urgent	Within 60 minutes	2,919,212 (44.6%)
Non-urgent	Within 120 minutes	723,273 (11.05%)
Total		6,540,832

4.2.3The number of critical and acute unscheduled patients who present at Australian emergency departments

In Australian emergency departments, a significant proportion of patients arrive with life-threatening disease or injury that requires high complexity decision-making to prevent further deterioration. From the information in the above table, we calculated that 690,386 emergency department patients (or 10.55 percent of the total) were placed in the two top triage categories in 2011–12. These patients required the delivery of critical care. A further 2,198,840 (or 33.6 percent) required the delivery of acute care. Together these figures represent 44 percent of all Australian emergency department patient presentations in 2011–12.

4.2.4Most emergency department patients are undifferentiated

Many patients arrive at emergency departments without a definite diagnosis. Without a clear diagnosis, doctors cannot predict the behavior of the illness, which means that the urgency and the quantity of resources required to treat the patient are unclear. Hence the undifferentiated patient presents emergency department doctors with a clinical challenge not usually faced by doctors working in in-patient wards.

4.2.5Time and safety are closely connected in emergency departments

Approximately 63 percent of patients who present at emergency departments are either admitted to hospital wards or discharged home within four hours of arriving at emergency departments (NSW Health 2013). Doctors and nurses delivering critical and acute unscheduled care in the emergency department often have minimum information and little time to grasp the patient’s clinical situation and have to be one step ahead of the evolving disease or injury to keep the patient safe, particularly in cases where patients are critically or acutely ill. Hand in hand with complex decision-making in the emergency department is the need to maintain high standards of information transfer during clinical handovers across shifts and across wards.

4.2.6Emergency departments are characterized by high levels of noise and constant interruptions

Doctors and nurses working in the emergency department have to compete with constant high level ambient noise from monitors, patients in distress, background talk from other teams working in close proximity and the sound of moving trolleys and equipment. They also manage multiple disruptions including phones, pagers or requests for information and assistance. In combination, these present significant challenges to communication and collaborative decision-making processes.

4.3The communication challenges of hospital emergency departments

The unique contextual factors in emergency departments mean that communication in emergency departments is highly challenging. We identify seven factors that make communicating in this environment very different from communicating in most other workplaces that provide medical care.

4.3.1Episodic care

As a rule, patients, doctors and other health professionals meet at the bedside as strangers. They come together in the emergency department through circumstances and the staff roster and in the emergency department context health professionals often have little time to build relationships with patients during what can be a stressful and uncertain time (Garmel 2012).

4.3.2Challenges to building alliances between emergency department team members

Emergency department team members have no choice but to work together to provide patient care in hospital emergency departments (NSW Health 2012). However, building professional alliances between team members is not always a simple matter. For example, emergency department team members include people of different professions, training backgrounds, levels of experience and expertise, different ages and gender. Also, communication and personality styles vary. A lack of time, the urgency of the clinical situations of many patients, combined with associated uncertainties, add to these challenges.

4.3.3Poor access to clinical information

For a proportion of the total number of patients who present at emergency departments, doctors have little or no access to clinical information in the form of written or electronic patient notes. In these cases, doctors have to gather information at the bedside, either by talking to patients and families/carers or through clinical processes (e.g. examination and investigations) where conditions are not always ideal. Communication options are considerably reduced when patients arrive at the emergency department with acute illness or injury.

4.3.4Second language issues and poor health literacy

Generally speaking, patients who are conscious and alert are a valuable source of information about their own health. However, patients and their families/carers who have second language issues combined with poor health literacy present challenges to communication in emergency departments. Many young doctors in Australian emergency departments also have second language issues and these can create additional problems, particularly during clinical handover.

4.3.5Different grades of experience and applied knowledge

All emergency department teams are made up of doctors and nurses with varying levels of applied clinical knowledge and experience. If experienced doctors make assumptions during emergency department medical handovers about the level of understanding of junior doctors and nurses, then problems can arise during clinical handover, particularly when juniors fail to seek clarification. Our research findings showed that junior doctors rarely sought clarification or asked questions during clinical handover.

4.3.6Medical hierarchy of responsibility

Since many inexperienced junior medical officers perceive the medical hierarchy of responsibility as a hierarchy of power (refer to the section on interviews in the previous chapter), junior medical officers are often over-deferential towards seniors. The result is that many junior medical officers are reluctant to offer medical opinions or information, to ask questions or seek clarifications during clinical handover, even if this has implications for patient safety.

4.3.7High safety stakes

High standards of information transfer during clinical handovers are necessary to maintain patient safety in all hospital care situations (Wong et al. 2008; Ye et al. 2007; Nagpal et al. 2010; Jorm & Iedema 2008), including in the emergency department. Communication strategies involved in the safe transfer of information during clinical handover include the systematic transfer of accurate, complete and relevant patient information and the inclusion of all team members in the decision-making process. However, in critical and acute unscheduled care situations in the emergency department, the patient safety stakes are significantly increased, and the margin for error during clinical handover is dramatically reduced. These latter situations inevitably increase the pressure on health professionals to communicate effectively.

4.4Five key principles of clinical handover practice

We now move from our broad analysis of the challenging context and communication in emergency departments to focus specifically on clinical handover practice. From our observations, interviews with clinicians and analysis of communication data we suggest five principles that are essential to ensuring safe and effective clinical handovers in the emergency department.

4.4.1Patient safety is at the center of clinical handover practice

Clinical handover has been described as a procedure that is potentially perilous for patient care (NSW Health 2009). Consequently, providing safe, quality care and patient care continuity are key functions of clinical handover (Smeulers et al. 2012; Manser 2011; Apker 2007; Bomba & Prakash 2005). One important way to provide safe, quality care is to make patient needs the focus of clinical handover communication.

To ensure that patients’ needs remain at the center of clinical handover, in practice emergency department doctors need to:

4.4.2The transfer of responsibility and accountability is a core function of clinical handover

Clinical handover centers on the exchange of accountability and responsibility for the safe care of patients (Jorm & Iedema 2008). It is crucial that this chain of accountability is not broken during transitions of care (NSW Health 2009). The way healthcare professionals maintain responsibility and accountability for the ongoing care and safety of patients is to transfer accurate and relevant patient information during clinical handover and at the same time to make the transfer of responsibility and accountability clear.

4.4.3Clinical handover is an organizational process

Emergency department medical handovers are triggered by shift changes, which are one of the institutional ways that the work schedules of emergency department personnel are organized. Clinical handover itself includes a complex organizational process that doctors and other health professionals use to provide continuity of care for patients. In the emergency department context, the continuity of care for patients begins with the initial response to a patient’s presenting symptoms and continues until the patient is either admitted to hospital or discharged home. During clinical handover, doctor-led teams make collaborative decisions about how each patient’s continuity of care should be organized. For example, they allocate tasks and actions to different team members, depending on their level of experience and expertise, so that appropriate treatment can be delivered. Thus it is equally important for junior and senior members of the emergency department medical team to participate in clinical handover.

4.4.4Clinical handover depends on teamwork

Healthcare teams deliver multidisciplinary care. Consequently, teamwork and collaboration are an essential part of keeping patients safe in healthcare contexts (NSW Health 2014). Teams are made up of people from a range of disciplines, depending on a patient’s clinical needs. For example, in a hospital emergency department, the team of people involved in the care of one particular patient may include doctors, nurses, a social worker, a physiotherapist and a pharmacist. Some or all of these team members may attend an emergency department medical handover at one time. Doctors, nurses, pharmacists and social workers all focus on different aspects of care and thus have varied information needs during clinical handover. The onus is on all emergency department team members to engage with and try to accommodate the varying professional information needs within the team in order to achieve multidisciplinary care. Improvements to clinical handover will follow if all health practitioners place more emphasis on the value of engaging and participating in the process together (Svabo 2010; Gherardi 2008).

4.4.5Clinical handover combines action, talk and relationships

Clinical handover is a professional practice that combines the things that people say with the things that people do, often with others (Green 2009). Crucially, in the emergency department the things that people say and do when they are giving clinical handover are affected by the many different relationships and connections that people form as part of doing their work (Kemmis 2009). Doctors develop relationships and connections with medical colleagues (often hierarchical), with nursing staff, with allied health professionals, technicians and administrative staff and with patients – any one of whom may have a part to play in the ongoing care of patients.

In our research study of emergency department clinical handover (see previous chapter) we observed and recorded a repertoire of repeated activities (Gherardi 2008) at the bedside that were associated with clinical handover. Some of these activities included: the way team members habitually stood at the bedside; the way doctors checked patient notes, scans and test results to confirm information; and the way different team members wrote down information (e.g. scribbled on a piece of paper or recorded as notes on a printed sheet). We also audio-recorded what team members said at the bedside and found that particular information was regularly transferred during clinical handover. For example, the identity of the patient, the immediate clinical situation of the patient, the most recent observations, background information related to the presenting problem, identification of tasks for the next shift and plans for further care. We also observed the different ways that team members engaged in communication. We identified particular patterns of engagement that reflected the roles and responsibilities of team members: senior doctors were more likely to discuss patients with other senior doctors and junior medical officers made minimal contributions to discussions about ongoing care. In fact, unless they were giving a handover at the end of a shift, junior medical officers often made no contribution at all: they asked no questions and sought no clarifications. In other words, the level of engagement between senior and junior team members was often not optimal for teaching and learning to occur during the clinical handover.

4.5Five key principles of clinical handover communication

The five principles of clinical handover outlined above lead logically to five principles that we believe should inform/govern clinical handover communication.

We briefly explain each communication principle below.

4.5.1Patient safety must be the focus of clinical handover communication

Patient safety is central to any clinical handover exchange. It follows that patients and their ongoing care should be the focus of communication each time participants give a clinical handover in the emergency department. This applies during both scheduled and ad hoc transitions of care, such as shift changes and tea breaks, respectively.

4.5.2The transfer of responsibility and accountability for ongoing patient care must be made explicit during clinical handover

The rationale for clinical handover, which is to mark an explicit moment of transfer of responsibility and accountability during ongoing care, is clearly reflected in the Australian Medical Association’s (2006) definition of clinical handover as:

the transfer of responsibility and accountability for some or all aspects of care for a patient, or a group of patients, to another person or professional group on a temporary or permanent basis. (AMA 2006)

It therefore follows that doctors must acknowledge explicitly the transfer of responsibility and accountability for all patients during clinical handover. The outgoing doctor can do this by making it clear to colleagues that s/he will complete particular actions over the following shift:

‘OK. I’ll follow up on the blood results immediately after the round.’

‘OK. So … I’ll contact radiology and book him in for a scan for this afternoon. After that I’ll let the family know.’

The incoming doctor can acknowledge the transfer explicitly by introducing himself/herself to the patient and/ or family members. For example,

‘Hello Mrs P. I’ll be looking after you for the next shift. I’ll be back to see you soon.’

4.5.3Clinical handover participants must make team decisions about how each patient’s continuity of care is organized

The organizational component of clinical handover is crucial to ensuring the provision of safe, continuous care. All team members, including medical, nursing and allied health professionals, must therefore be included in any discussions about the kinds of tasks that will be required to provide appropriate levels of care for each patient and to allocate specific tasks to team members for the following shift or care period.

4.5.4Clinical handover participants must actively share and discuss patient information with other team members during handover

Different disciplines have different perspectives on patient care and thus have different informational needs during clinical handover. Doctors giving handovers need to keep in mind the informational needs of all team members, not just those of their immediate medical colleagues. Senior clinicians can recognize this by supporting an ‘opportunity to speak’ approach when they give clinical handover, so that other team members can contribute information that they consider relevant.

4.5.5Clinical handover participants must negotiate both the informational and the interpersonal or interactional dimensions of clinical handover

The communication of information during clinical handover supports the transfer of patient care between individuals and teams of healthcare professionals and preserves professional responsibility and accountability (Mistry 2010). During clinical handover, team members need to communicate with one another in order to exchange clinical information and opinions, to discuss and review previous actions and tasks and to review previous diagnoses and treatment plan decisions (Cunningham 2009). Team members also need to include patients in any handover communication since the patient’s care is the focus of the discussion. In addition, as part of this communication process, team members need to develop positive professional relationships and connections with other team members (Kemmis 2009). As explained in our previous chapter, the findings from our research study of clinical handover practice support these claims by showing that the communication of patient information has both an informational and an interpersonal dimension. These dimensions are discussed below.

4.5.5.1Informational aspects of clinical handover

Doctors gather patient information from the point of a patient’s arrival at a hospital emergency department. Next doctors synthesize this information before it is shared and discussed by the team. Finally, team members co-construct an up-to-date patient management plan. A patient’s safety is dependent upon the accurate dissemination of this information among all those involved in the patient’s care. The information that is shared during clinical handover generally includes:

4.5.5.2Interpersonal aspects of clinical handover

Clinical handover communication in the emergency department should include all medical, nursing and allied health team members and, where possible, patients as well. In our research of emergency department medical handover practice (see previous chapter) we found that patients were rarely included in clinical handovers. However, patients are key stakeholders in the process of clinical handover, and there are two compelling reasons for including them in the communication where possible. First, involving patients and carers can enhance patient safety and reduce patient risk (e.g. patients can add information or correct information that is inaccurate). Second, patients can make known to team members their concerns and treatment preferences (ACSQHC 2012b).

Clinical handover participants will manage patient information and team communication better and are more likely to share the same, accurate clinical picture at the end of the clinical handover when they seek to co-construct a clinical picture of the patient. Communication should be a two-way process to allow team members to take turns to talk, to interrupt one another, ask questions, seek clarifications, contribute information, contradict one another and to use eye contact and body language to make non-verbal signals. This kind of collaboration among team members is achieved only when speakers and listeners both play active roles during clinical handover.

The speaker’s role involves a number of steps. First, speakers need to transfer patient information, responsibility and accountability for the patient when they hand over the care. Second, speakers need to be aware of their listeners’ communication needs, which are to receive a clear, concise and accurate picture of the patient’s current condition, along with a clear understanding of what actions their listeners need to perform over the following shift. Finally, speakers need to engage directly with their colleagues to negotiate shared decisions, to discuss treatment options and to disagree if necessary.

The listeners’ role also has a number of steps. First, listeners need to focus carefully on the information content. Second, if they are taking over the care, they need to accept explicitly responsibility and accountability for the patient. Third, they need to ask speakers to repeat or clarify information that is unclear, for example because of second language issues, or that is inaudible because of the high levels of noise typical of emergency departments. Fourth, they need to engage and participate directly in any subsequent discussion about the patient by contributing information or opinions that they decide are relevant to the patient’s ongoing care and safety. Finally, they need to seek clarification if they are unclear about the tasks or actions they are required to do during the following shift.

Apart from establishing relationships with patients and building professional relationships with colleagues, other interpersonal functions of clinical handover include team building, role modeling of practice and professional identity (Manias et al. 2008; Patterson et al. 2004; McFetridge et al. 2007; Solet et al. 2005) and developing an understanding of the hierarchy of experience and authority in hospital contexts (Bomba & Prakash 2005).

4.6Communication strategies to strengthen clinical handover

We now present the practical communication strategies that we include in our training module. In presenting this module we ask junior medical officers to apply the strategies to various clinical handover scenarios adapted from transcripts of real life handovers from our research study. Consistent with the principles identified in the previous sections, we organize the strategies under the two subheadings of informational strategies and interpersonal strategies. To simulate the training context, we address the strategies directly to junior medical officers.

4.6.1Informational communication strategies: how to facilitate the exchange of information during clinical handover

4.6.1.1Prepare for clinical handover

Prior to transitions of care, outgoing doctors need to gather relevant patient information and make sense of it. For the outgoing doctor, this involves combining what you have learned from the patient with your general medical knowledge so that you can formulate an understanding of each individual patient and their illness. It is this synthesized version of the patient’s information that you will transfer to colleagues during the clinical handover.

Junior medical officers can make a significant contribution to the safe care of patients by eliciting information in the same order each time during the initial assessment and stabilization stage, recording any information that is relevant to the patient’s presenting problem and then sharing it with the interprofessional team during clinical handover. (Refer to chapter 5 of this book for tips on efficient ways to gather patient information during the initial history taking, examination and investigations stage of the emergency department visit.) It is reasonable to claim that about 85 percent of a diagnosis is based on the medical history.

4.6.1.2Manage the context

As the outgoing doctor, before you begin to transfer information to your colleagues, take steps to manage the noisy and disruptive environment of the emergency department to achieve the best communications outcomes possible.

4.6.1.3Use a consistent framework to transfer information

Use an information framework to provide information during clinical handover, such as the one we provide in Tab. 4.2 below. This will make omissions of patient information much less likely. Using a systematic information framework also helps you to maintain your train of thought. In addition, if both listener and speaker use the same framework, interruptions are less likely because listeners can anticipate what information is coming next.

4.6.1.4Make sure the information framework is logical

A logical information framework (‘this leads to that’) will facilitate shared decision-making and assist the emergency department team in the co-construction of appropriate management plans. The advantages of a logical framework are:

4.6.1.5Use signposts to structure information at the sentence level

Often a great deal of information relating to different aspects of care is shared during clinical handover and many exchanges during clinical handover are complex. Disorganized information is not uncommon (see previous chapter). You can make your information more accessible to listeners by clearly signposting what you are about to say when it is your turn to speak. Use signposts to achieve the three functions below.

Tab. 4.2: Information framework for emergency department clinical handover (medical)

Structural elements	Text examples
1. Opening Greet the patient and explain that you are going to do a handover. Orient listeners to the start of the clinical handover process by getting your listeners’ attention. Give the team a moment to ready themselves for the next transfer of information.	Hello Mr Ahn. We’re just going to hand over your information to the new team. OK. So, next, the handover for bed 5…
2. Priorities Outline the major issues of concern. Indicate outstanding tasks for the next shift; etc. (This is key information you need listeners to take away with them – so they can act).	The key issues for this patient are: i)The patient is stable, but we have no diagnosis yet. CT and blood results are pending. ii)The patient is not well and needs to be admitted. He has a fever of unknown origin. iii) The patient needs to start antibiotics as soon as possible and requires an isolation bed.
3. Verification and synthesis of information Verify the patient’s personal details. Synthesize a sequence of information that is focused on the patient’s safety by adding your own medical knowledge to the information gathered from the patient. Organize the information into bundles and clearly signpost it so that listeners can identify changes in topic. Use the same sequence routinely as a self-checking mechanism.	So to begin…Mr Ahn’s a 65-year-old male. He presented with severe abdominal pain. He has a background of… His medications are… His allergies are…His social history is…On examination we found…Investigation results show…The medical treatment plan is to continue with the antibiotics…The disposition plan is to admit the patient under Respiratory…
4. Discussion Discuss your findings with other team members to review the initial diagnosis, care priorities, patient information and/or the management plan provided above if necessary. Engage in a process of shared decision-making to reach agreement on a treatment/management plan. Support ‘opportunity to speak’ approach for all team members.	A. So, the hematemesis has not recurred in the emergency department and there is no melena. B. Yes and he is hemodynamically stable. He has no indicators for an urgent endoscopy. A. OK, so we should admit him and keep him fasted for endoscopy later…? B. Yes, I’ll ring the team.
5. Conclusion Conclude the clinical handover by orienting listeners to the end of the process for each patient. (Add a summary of the information; highlight the ‘to do’ list again and allocate tasks; check for agreement about the management plan; close the clinical handover for each patient). Acknowledge the patient before the team moves on to the next clinical handover.	So in conclusion, we’ll admit him under gastro. Keep him fasted and Dr Lin, please write up the fluids, and the pain relief. Also inform the patient’s family that he’s needing to come in and I’ll speak to the bed manager to organize a bed. OK? All clear about what we’re doing for this patient? Good. Thanks Mr. Ahn.

1.Use signposts to introduce new topics: signposts allow you to emphasize key words as a way of organizing information into separate bundles:

–Provide clarification and/ or explanation for what is to follow: circumstantial information will allow you to explain what, why, when, how:

4.6.1.6Explain your reasoning

To be sure that everyone in the team has the same understanding of the clinical situation at the end of clinical handover make your reasoning explicit:

4.6.1.7Maximize the effectiveness of your information delivery

If you adopt the four strategies described below your listeners will find it easier to follow what you are saying.

4.6.1.8Don’t assume knowledge

Emergency department teams include health professionals from a range of different professions and with different grades of experience and expertise. As a result, some senior level information exchanges or negotiations during clinical handover will be difficult for the less experienced or less informed to follow. The examples provided below were taken from our research data (see previous chapter) and the clinical significance of the information may not have been evident to junior medical officers on the team:

‘He has an elevated CSF protein’: junior medical officers may not have understood the clinical implications of a raised CSF protein level

4.6.1.9Avoid using vague terms

It is crucial that accurate information is exchanged during clinical handover. The use of imprecise language may mean that different team members have a different understanding of the patient’s clinical situation at the end of the handover. When presenting the information, use medical conventions and terminology (see the following chapter for more examples). The following phrases from our research data (see previous chapter) illustrate the difficulty of creating shared understanding among team members when using vague, non-medical terms during handover:

4.6.1.10Provide your listeners with clear information distinctions

To avoid confusion, differentiate clearly between sets of information such as the disposition plan and the medical treatment plan:

4.6.1.11Be aware that newcomers may not be familiar with medical terminology

All professions and workplaces develop specialist terminology. It is easy to forget that terminology can be challenging for newcomers, particularly junior professionals and those who have only recently arrived at a particular workplace. The example below makes it clear why this is the case.

4.6.2Interpersonal communication strategies: how to facilitate the relationship between speaker and listener during clinical handover

It is often poorly managed spoken exchanges between team members that result in the description of clinical handover as a ‘high risk scenario for patient safety’ (Wong et al. 2008). There are numerous communication strategies that can facilitate the relationship between speakers and listeners and thus improve the exchange of information. We list some of these strategies below.

4.6.2.1Establish rapport with team members

Emergency departments can be stressful places to work so it is important to maintain a professional approach to communication with both patients and colleagues. A simple way to establish rapport with colleagues is to respectfully acknowledge their contributions and their questions and to address them by name, e.g. ‘OK. Thanks, Dr Lin.’

4.6.2.2Make it clear who is responsible for outstanding tasks

Address colleagues by name when allocating tasks or checking responsibility. For example:

4.6.2.3Indicate to the speaker when you want to add information

Simple requests or non-verbal signals will allow you to interrupt the speaker politely so that you can add information to the clinical handover which you think is relevant.

For example:

4.6.2.4Indicate to the speaker when you want to confirm information or ask a question

As noted in our previous chapter, junior medical officers rarely confirm information or ask questions during clinical handover. Yet emergency department clinical handovers provide junior medical officers with an ideal opportunity to engage and participate in a learning process under the guidance of more experienced practitioners (Lave & Wenger, 1991). Confirmations and questions from junior medical officers are anticipated, even expected.

4.6.2.5Ask the speaker to clarify or provide further information

4.6.2.6Find out information you do not know with WH-questions

(Wh-questions are Who, What, When, Where, Why, How).

4.6.2.7Explain why you are asking

4.6.2.8Confirm information with yes/no questions

4.6.2.9Clarify information with assumptive questions

These are questions in statement form:

4.7Conclusion

The numerous contextual and communication factors that are present in emergency departments combine to make the practice of clinical handover a challenging one. However, there is a sequence of steps that junior doctors can take to develop and strengthen their own handover practice. The first step is to be familiar with the key principles of clinical handover practice and communication, which we have summarized in Tab. 4.3 below.

The second step is to prepare for clinical handover prior to the transition of care and to use the same logical and systematic framework for the transfer of the information during every clinical handover. For those who are transferring information, the benefits of using the same framework include organizing information in a logical way, avoiding crucial omissions of information and maintaining a train of thought despite the frequent distractions and interruptions that are a normal part of the emergency department environment. The benefits for listeners include receiving the flow of information in a logical sequence, which encourages clear thinking and allows the incoming team to anticipate what information is coming next, thus reducing the need to seek clarification or to ask for further information from the outgoing doctor.

The third step is for junior doctors to adopt useful communication strategies that they think will help them to make their information more accessible to listeners and thus improve opportunities for the collaborative exchange of information and medical opinions. Some of the strategies we presented here include signposting information, avoiding assumptions about understanding, seeking clarification or asking questions, as well as suggested ways to provide a rationale for decisions and for asking questions.

Finally, junior doctors can strengthen their clinical handover practice by thinking about clinical handover in a slightly different way. While we acknowledge that the transfer of patient information and responsibility for care are primary roles of the clinical handover process (NSW Health 2009; Bomba & Prakash 2005; Nagpal et al. 2010), we also understand that interpersonal communication processes are an essential part of the management and the transfer of patient information. We encourage doctors in training to think about clinical handover as a complex practice based on collaborative professional exchanges, which provide valuable learning opportunities in clinical thought, decision-making and information exchange. Clinical handover is also about establishing and maintaining professional relationships, team building and a crucial way to keep patients safe while they are receiving hospital care.

Tab. 4.3: A summary of the principles of clinical handover practice and communication

Five key principles of clinical handover practice	Five key principles of clinical handover communication	Examples
1. Patient safety is at the center of clinical handover practice.	1. Patient safety must be the focus of clinical handover communication.	Doctor A: She’s on Metoprolol? Um, has she got acute heart failure? Because Metoprolol suppresses the pumping action.
2. The transfer of responsibility and accountability is a core function of clinical handover.	2. The transfer of responsibility and accountability for ongoing patient care must be made explicit during clinical handover.	Doctor A: Right so she’ll need to be admitted. Chest X-ray ordered I assume? Doctor B: Um, I’ll add it on. Doctor A: And she’ll need to be monitored. Doctor B: Yes. Got it.
3. Clinical handover is an organizational process.	3. Clinical handover participants must make team decisions about how each patient’s continuity of care should be organized.	Doctor A: Would you order the chest X-ray? Doctor B: Yeah, yeah. Doctor A: And I’ll chase up the social worker and organize the bed in Respiratory after the round.
4. Clinical handover depends on team work.	4. Clinical handover participants must actively share and discuss patient information with other team members during handover.	Doctor A: I would probably add some Flagyl as well. Doctor B: Flagyl? Yeah that’s fine, I’ll add the Flagyl, just to cover her.
5. Clinical handover combines action, talk and relationships.	5. Clinical handover participants must negotiate both the informational and the interpersonal dimensions of clinical handover.	Doctor A: What antibiotics is she on? Doctor B: Um ceftriaxone and um, clarithromycin. Doctor A: OK. Dr Lin. And what about feeds?